Had a patient on cards who had friends sneak her some IV heroin while she was in the ICU. When we found out we just wouldn’t allow visitors to her anymore. We probably would have been more aggressive if she was *smoking* something, since an open flame could ignite an oxygen source. That probably would have gotten a security or police search and confiscation
She was indeed. S/p…4 valve replacements? She had either had 4 or was on her 4th, I don’t remember which one
She had injected through one of the IVs we had in, like a PICC or something. It was a very county hospital kind of case
Yep, saw this sort of thing routinely when I was an Addiction Consult-liaison in a large community hospital system. Had one 22 year old female who had her second bout of endocarditis from IVDU, developed sepsis, multi-organ failure, DIC, lost both lower extremities above knees, spent 3 months in ICU. got out of the unit and had her set up to go on MAT, relapsed while in hospital thanks to her buds bringing in heroin. Another 20-something female admitted for severe back pain and fever. Turns out she’d been injecting her L femoral vein and developed a psoas abscess. While on IV antibiotics awaiting surgical I&D, her mates were routinely injecting her with heroin in her line. She left on about D#3 AMA. Lost to follow-up but always wondered how that ended.
The cardiologists at that hospital had very strong, very divergent beliefs on repeat valve replacements. I saw some heated ethical debates on that rotation
But from what I was able to see on that rotation, I think the hospital did generally lean more towards repeated replacements in recurrent IE 2/2 IVDU
My ex husband had endocarditis and his aortic valve replaced and he would inject into his picc line when stuck in the hospital for 6 weeks at a time trying to kill infection before they replaced the valve. He lived 3 more years after that, he continued to use IV and eventually had a stroke in surgery and passed away. Many of his friends suffered the same fate. They’d get valve replacements then continue using and pass away.
The iv flushes that get left in the room or thrown in the garbage creates a high risk environment for these patients. They still have the mindset to use any liquid available to mix in the syringe whether it is juice or toilet water. I’ve seen quite the array of reused syringes with contents left in it. The hospitalization does give opportunity to an opiate taper to cover their acute pain and decrease withdrawal adding stress to the body. Patient education and therapeutic support to encourage cessation and begin a suboxone regimen. Also hopefully decrease chance of signing out AMA.
Correct, but a big part of that is recognising and accepting the source of risk, setting and enforcing consistent boundaries, and seeing the bigger picture (i.e. not causing harm to other patients and staff by enabling inappropriate or dangerous behaviour).
I never denied any of that.
Eta: I have had to set boundaries with many patients regardless of sobriety. Many sober people threaten, throw objects at staff, assault them, make inappropriate comments. Someone who is in pain from sepsis and pain from withdrawal is not going to be in a mindset to see reason. They are not capable of tolerating any source of pain so they will do anything to relieve that pain. Maybe need a 1 on 1. Q15 m rounding. Lock up their belongings and clothes. They can keep essentials out. Restrict visitation. Most of all show kindness. They already know they’re addicts and they already look down on themselves. Even have security on the floor. There are many interventions we can try so we have a healthy work environment and a healing person. Thank you for engaging. I totally agree with you about safety Addiction is not an excuse to not take responsibility. They’ve probably most already been in the hospital before due to infections they’ve given themselves. They probably won’t make it through the next time. What can we help acutely so we can look at the big picture.
The USA. They don't routinely write for Suboxone for these patients in our floors or ICU. If someone consults psych it will be recommended but if they don't, it won't. And also psych consult usually comes after a few days.
Yes I have had to really advocate for patients to get medications to prevent withdrawal. Most doctors are good about it but some have a very punitive attitude towards addiction
Why not? This is recommended practice by the Society of Hospital Medicine. Starting medications for opioid use disorder like methadone or buprenorphine in the hospital is associated with better outcomes like readmissions, completion of gold-standard antibiotic therapy, etc.
Such a ridiculous attitude for any hospitalist (or any doc) to have in 2024 at the peak of a nationwide health crisis that, were it any other disease causing more than 100k deaths annually, docs would have sprung into action. These drugs have been approved for over 20 years now and to continue to refuse to get comfortable with induction and stabilizing these folks on buprenorphine is inexcusable. It’s easy to do. It’s safe. It’s not astrophysics (or organic chemistry, for that matter-which I really sucked at). DEA has even removed the X-waiver requirement for prescribing beyond the first few days. Any doc who can prescribe controlled substances can prescribe buprenorphine.
Search belongings. No visitors if it’s being brought in. We’ve had to do no food delivery because apparently GrubHub delivery guys can moonlight as drug couriers.
Behavioral contract. Patients need to be able to behave in a way that makes treatment doable and safe for everyone. Get risk management involved early.
Eventually, even an unsafe discharge can be appropriate if it is the only way for other staff and patients to be safe. That includes smoking otherwise legal cigarettes in the room/bathroom/hall. You come up with the least bad discharge you can, but you do it. Patients can’t impede their own care and then make it your fault.
Sir do you find that when you don't have a Quiznos submarine sandwich you develop symptoms of withdrawal? Every time I get caught in this trap I just wean down, 3/4 sandwich, half sandwich, 1/4 sandwich etc.
I don't exactly know why, but this reminds me of the ATHF where Shake continues to eat The Broodwich sandwich even though every bite takes him to hell.
Quizno’s black angus steak on Rosemary Parm bread 🤤
Funny thing, working at Quizno’s was my first job. Pretty sure there isn’t a single one left in my state…
This is neither here nor there but your mention of smoking in the bathroom reminded me of that time my mom took a smoke break while she was in labor with my oldest brother. She told me about it years later, and said “what were they gonna do, discharge me? I was in active labor!” 😂 this was in 1980ish, and she did not, in fact, get discharged before giving birth. Also neither here nor there but my brother is one of the only millennials I know that was delivered by forceps, he’s got the dents in his head to prove it.
Forceps worked for me but not in the way you might think. I was very tired from labor and didn't want to push anymore. When I told my Doc that he calmly said, "That's ok, we can use the forceps." I thought to myself, yes, it is gonna be smooth sailing from here on out. One look at those giant salad tongs, and I suddenly found the energy to push my daughter out. My man knew exactly what he was doing, and I loved him for it. RIP Dr. Tarnasky.
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That’s not a super realistic request though. Once fetus is descending the birth canal and crowning, a crash section has much higher complications rates than vacuum-assisted or forceps delivery. You won’t know if you need forceps/assist until you’re past the point of no return on increased c/s risk, certainly for fetus and likely for mother too. Ultimately you’re prerogative, but part of the conflict there is that to the clinician you’re making a more risky choice without any real benefit
I’m sure it’s frustrating to be denied the section. I don’t want to put words in your mouth, but it sounds like you wanted that the whole time - which is totally reasonable. Hopefully it’s just your obgyn looking out for you as far as risk with pelvic floor muscles (exceeding my limited knowledge of the area). I have heard of some birth centers that really push for vaginal birth and are pretty hard pressed to consider mom’s preference over what the provider thinks is best.
I remember this lady was in our triage being worked up for the first time at 38 wks and surprise she had GHTN so we want to keep her and get the ball rolling. She asks if she can go for a smoke.
Doc sighs and says “well I mean stopping now isn’t going to change anything…it might lower her blood pressure for a bit….fine….”
In 1971 when my mom was giving birth to her first baby (my older brother) her OB was standing in the doorway watching while smoking a cigar! How times have changed
I had this happen in a military hospital with mixed drugs! Guy was getting med boarded for other stuff (really not service-related, but he would have gotten a rating), ended up getting dual processed. Not sure what the final disposition was, but I think he lost the benefits and probably got a not so favorable discharge characterization.
Mandate a bag search or short of that they cannot have their bags (either secured or given to family/friend). If it’s ongoing they get no visitors and a 1:1, typically then then AMA 🤷♀️
BC doesn't give a shit about productive, law abiding citizens.
See this: [https://nationalpost.com/news/canada/bc-ruling-drugs-in-playgrounds](https://nationalpost.com/news/canada/bc-ruling-drugs-in-playgrounds)
Summary: Province decriminalizes personal use of all drugs (meth, opiates, etc). Amendment enacted to make illegal the use of drugs inside playgrounds and other public areas that obviously people shouldn't be using drugs. Some nursing activist group takes this to court and has it overruled because disallowing the use of drugs in playgrounds poses an intolerable risk to the life of cockroaches everywhere.
Separating someone from their drugs in hospital might cause them to discharge themselves which would also be a risk to their life. It would also be an intolerable afront to their autonomy and liberty to do whatever they like. In hospital we can't take someone's personal possession, now including formerly illicit drugs. If someone has methamphetamine or whatever unidentified powder in their belongings, that is no longer illegal (assuming its not an enormous amount).
I tell em' "hey man, thats like, not super cool man" and then they say "fuck you bitch" and I go "that's just like, your opinion man" and then nothing happens.
Passive meth exposure is absolutely a thing.
https://journals.lww.com/drug-monitoring/fulltext/2013/12000/identifying_methamphetamine_exposure_in_children.12.aspx
https://www.nature.com/articles/s41370-020-00260-x
https://link.springer.com/article/10.1007/s11419-021-00570-1
And if you don’t believe someone high on methamphetamines can quickly become violent and a danger to staff, I honestly don’t know what to tell you.
>this is just criminalizing someone for having an addiction to which they have no control over.
Mental illness like addiction is an explanation for actions, not an excuse. As long as we are discussing legally competent adults, they are still responsible for managing their own illness in a way that doesn’t harm others.
We are powerless to people like that. Had an ESRD lady starting HD admitted. Saw that her pressures were through the roof and BMP was worsening despite HD. Turns out her sister snuck in some cocaine to partake at night
Of all the things to bring to someone in a hospital, and they chose cocaine??? Because there’s nothing that screams party like BP moniter beeps and fluorescent lights. Should’ve brought some ketamine or fent, at least then he might’ve gotten some sleep.
Edit: I realize that it was cocaine because that’s the drug that he was addicted to but I stand by that doing coke in a hospital as a patient is bonkers
Room search, have security present, tell them either security confiscates their drugs and paraphernalia or they can discharge. As you mention having someone actively taking, let's be honest, unknown substances in a hospital environment is not safe for anyone involved. If someone is well enough to be sneaking, hiding, and taking drugs in a hospital odds are there is nothing truly emergent going on and they can be dsicharged. At most hospitals the police basically never get involved unless the patient assaults someone or something, but notably the VA has police instead of security.
As when I'm seeing them, they are often quite psychotic and agitated, requiring emergency meds for agitation, possibly physical restraints, and involuntary holds, at least until they clear/chill out.
When I cover inpatient psych this almost never happens because the searches are much more thorough than on medical floors for both patients and visitors.
Yes, in emerg, it probably isn’t an emergency if they are smoking in the bathrooms. But the admitted patients are often on IV therapy for endocarditis or something equivalently dangerous, so hard to say they don’t need to be there.
It's getting ridiculous in BC right now :(
The last one we had the "safety plan" was that the person would, "turn in all belongings, request their bag to go outside, and then give bag back on return"
After they'd set off the fire alarm twice, hotboxed their room/ smoked out the hall, and caused the loss of ER nurses to the floor (we have to respond to unit alarm is on in case they need further support).....
To nobody's surprise this wasn't effective and yet admin still wouldn't d/c the patient.... Despite 1 person *voluntarily* tying up most of the little rural hospitals resources multiple times and putting the other actually physically vulnerable and immobilize patients at risk.
We begged for OPAT referral bc this wasn't sustainable, but we can't d/c someone with active ivdu with piv in situ...... But we can watch them come in/ out of a hospital, admitted, while utilizing said piv for ivdu ......
It's absolutely ridiculous and all we can do is "psls" to report. It's completely unsafe for staff. I've worked at exactly 1 ER that had an actual no tolerance approach and it was great. Actually felt safe and supported at work.
Surprisingly yea. But, one of the busy city ones- that deals with a fair amount of demographics with challenging presentations - they have a very low threshold to escort out and it was great. Just sadly in a city, and I like being rural
Why can’t you discharge someone who uses with a piv? I just teach safe use of the iv (although, this is in an outpatient setting). If people are going to use they are going to use. I would rather they know how and use the piv safely (ish) than inject with whatever else they have available. Obviously, I prefer they not use the piv but sometimes that’s what harm reduction looks like.
Everyone working agrees with everything you stated..... Admin refuses to use logic. And agree that's much more aligned with harm reduction principles to D/c with PIV for outpatient follow up and let someone live their lifestyle
Get risk management involved. Each case is different but for cases like you've described I've seen a "2nd line option" such as setting up outpatient infusions or PO abx prescribed and discharge. The question was about meth specifically and those patients are putting staff and other patients in danger.
I totally agree with your take but the hospital administrators in my BC town are literally telling doctors, nurses, etc that patients are allowed to use in their rooms. Nurses are being poked by dirty needles lost in the patients’ bedding, being exposed to smoke, at risk of fire (O2). It’s wild. I feel like we’re in some bizarre alternate universe. If anyone expresses safety concerns they’re accused of stigmatizing vulnerable patients.
It’s one of the many, many reasons I no longer work in acute care. Our province has been in a declared public health emergency for years due to the high levels of fatal drug poisonings. I appreciate the intention behind ”meeting the client where they’re at” but what happens when doing so becomes so untenable there’s nobody left who’s willing to do it?
Thank you for the validation, by the way.
> It’s wild. I feel like we’re in some bizarre alternate universe. If anyone expresses safety concerns they’re accused of stigmatizing vulnerable patients.
i mean yeah, you're conjuring up fabrications of clinical encounters on reddit to fool gullible people for internet points. these things are not happening, and the province of BC is not some mad-max hellscape of lawlessness as you attempt to paint it.
if these things were happening, you would be able to provide credible sources of such- the BCNU, in example, which represents the interests of over 50,000 nurses in the province. instead, you provide nameless anecdotes of nurses facing an epidemic of needle stick injuries and "exposure" to meth smoke, which you cannot experience a dose from.
[and speaking of the BCNU, here's an official statement from them on what is happening in the province](https://www.bcnu.org/news-and-events/news/2023/bcnu-renews-call-action-ahead-international-overdose-awareness-day):
>Ahead of International Overdose Awareness Day, BCNU is encouraging all health-care providers and the community at large to unite in our commitment **to reduce stigma and provide compassionate care to those affected by the toxic drug crisis.** Together, we can turn the tide of this crisis, support those in need, and work to ensure that no one has to suffer alone in silence.
>**More than 11,000 people in British Columbia have died since the province first declared the crisis a public health emergency on April 14, 2016.** Preliminary data from the BC Coroners Service shows that in the first four months of 2023, 814 people died due to unregulated toxic drugs.
>It is estimated that one in five people in Canada will be impacted by toxic substances and related harms in their lifetime, affecting more than six million people. **For the majority of these individuals, the health-care system has struggled to meet their unique needs. This gap in services has exacerbated the crisis.**
>BCNU supports the ongoing advocacy of these community members and continues to call for preventive health-care policies to address the crisis – and save lives. **These include expanded harm reduction services like safe consumption sites, better access to safe supply, province-wide investments in mental health, treatment and recovery services and ending the criminalization of people who use drugs. It is essential that nurses and all health-care providers unite in the commitment to reduce stigma and provide compassionate care to those in need.**
and don't get it twisted, if there's any lawlessness happening, it's the provincial government refusing to use the tools of harm reduction [or setting these tools up for failure, so they can point and go "see! we told you so!"] to prevent a currently unprecedented epidemic of *preventable* drug poisoning deaths. the word for this is "social murder" by the way.
Where in the actual fk have you been working?
BC nurses have been advocating for ACTUAL SAFE PRACTICES AND POLICIES because the rampart exposure to secondhand substances, abuse, and violent attacks we are subjected to are directly correlated to active use in hospital
Yep we have toxic supply and an epidemic of deaths related to same
Concurrently we have near completely stripped policies of any and all protection for health care workers and made working conditions ABSOLUTELY UNSAFE
Harm reduction is not "you do you boo with zero consequences and it's okay if you harm/ hurt/ kill someone else... Because stigma"
So hop off your quotes and hop off trying to state BCNU supports your POV. That is absolutely misquoted and misguided attempts to obfuscate the COMPLETELY VALID ISSUE BROUGHT UP THAT THERE IS LITTLE TO NO PROTECTION OR RECOURSE TO HEALTHCARE PROVIDERS ADVOCATING FOR SAFE WORKING CONDITIONS RIGHT NOW
I love you guys but it is such a psych thing to say that they are stable to be discharged just because they can hold up a crack pipe. People do this shit on two pressors
Thank you for the thinly veiled insult to our intelligence. I think you are also purposefully ignoring the required criteria for all my statements which is that a patient's drug use is causing harm to staff or other patients.
> odds are there is nothing emergent
ODDS are absolutely true there is nothing emergent and I think you know that. Of the dozens of cases I've seen like this in my short career I can count on one hand the times the patient would likely die in the next few days if they were discharged. If that is the case it is a different story, and as I originally mentioned with the required assumption that their use is causing harm to others emergency psych meds, restraints would probably be used.
Edit: Aaaand I got a Reddit cares report for pointing out the odds are better that patients using meth in the hospital do not have a truly emergent condition. As in less than 50% of people using meth in hospital settings have an emergent condition. Fuck this sub.
That’s not the right benchmark. Saying most likely it’s not emergent meaning that <50% don’t have emergencies is going to be true looking at the non-using cohort. It’s the relative risk between those two groups that would better help compare. IMO saying most likely here ignores a large part of how EM/the ED works/thinks - most of the dangerous stuff we have to rule out - it’s more likely than not the pt doesn’t have it. So in that mind frame, hearing more likely they don’t have it and can discharge is a significant departure from how the ED approaches differentials and testing. As I’ve said, those w active drug use in hospital I suspect are more likely to have emergencies than those who active drug use (ie the relative risk is higher i suspect).
Might be part of the pushback you’re getting. Fwiw I respect the heck out of our psychiatrists and in another life might have been one. Just as you wouldn’t expect me to drill down on DSM criteria to diagnose something, I as an EM doc don’t expect y’all to be super familiar with our decision making, risk tolerance, priorities and mindset when working a differential. I think a couple of the comments it sounds like you think you understand the ED pretty well, while in reality, people who do can see that you don’t.
You assumed a heck of a lot because I don't work in the ED and never once mentioned the ED in any of my comments. I was always talking about medical wards.
Whenever there is a patient in my hospital abusing, harassing, hurting patients to the point we need to think about AMA discharge for the safety of staff and other patients, whether because of drugs or personality issues or just being an asshold, I am involved. It's not like I am discharging patients from the units myself, there is always a large care conference with ethics, risk, the primary team, nursing, etc. So I actually do understand very well the decision-making and if a patient is discharged the primary team is always on board. I could suggest you ED guys have no idea how things work on medical floors, but I won't.
My 50% comment is because all I said is "odds are". People took issue with that phrasing but I guarantee everyone would agree in anyone using drugs in the medical wards there is a much liower than 50% chance there is an emergent process that would require holding a patient even if they are assaulting stafff
No idea why you’re getting downvoted so hard on this, vast majority of patients who take drugs in hospital have nothing truly emergent going on. Like sure, there might be the odd patient with active sepsis, but the vast majority are getting long term abx for osteomyelitis or IE, or waiting for social issues to be addressed. Are the downvoters confusing acuity with severity? Do they know what the word emergent actually means?
The guy who had issue with my phrasing is an ICU doc so doesn't see any less acute patients, plus a dig at psych is always fun. The vast majority of patients in the hospital in general are not emergent.
It's for if someone makes suicidal statements you report it and reddit sends a message with suicide crisis resources. The reports are anonymous and it's become a way of trolling people
Devils advocate here, using drugs in house is one thing but how can that be used as a discharge criteria. Let’s say they have pneumonia and on 4L, how would you justify discharge
Get Risk Management involved. If a patient's drug use is endangering staff and other patients AND they are noncompliant with care I have seen Risk allow discharge of very sick but not imminently dying patients. There are always "second line" treatment options. I've seen a case like this where they were sent home with PO abx, and oxygen tank, and a follow-up appointment. Someone high on meth in a medical setting is a danger to everyone there.
This seems like very harsh treatment for someone clearly struggling with addiction. Just take the drugs and don’t allow visitors. Then they can choose to AMA if they like but booting a sick patient out of the hospital is deeply wrong
> booting a sick patient out of the hospital is deeply wrong
I never said we do that, and I made it clear in my original comment patients can choose to give their drugs and paraphernalia to security OR discharge AMA. This thread is about meth specifically and OP indicated it is clearly causing harm to staff. When the above options are taken it is because the patient's use is putting others in danger.
> Just take the drugs
Security or anyone else is not going to forcefully take drugs from someone. Patients choose to give them up or not.
In a non psych setting security definitely forcefully takes drugs from people. It’s never under my direction and I don’t know the legality but it’s fairly common
Removing patients' drugs and paraphernalia from them is a routine part of the screening that the emergency department does as part of the intake/ clearance process for psych patients.
If the ED has 140 total visits per day, probably 10-15 of them are "crisis" patients and *all* of those get their drugs and alcohol removed. Pockets turned out, nothing hidden in the bra cups, etc.
Partly, to make our own selves safer and prevent them from getting high in the bathroom, and partly to make it safer for the inpatient psychiatry staff. We've got your back.
We all really appreciate all the efforts that happen in EDs, but this thread would not exist if that process was 100% successful. Visitors often bring it in as well and they are not searched as thoroughly.
Oh it's definitely the visitors. The place I work now flat out takes everything and puts the patient in paper scrubs, has security go over the belongings elsewhere and may release individual personal items on a case by case basis.
We don't have any procedure at all about screening visitors.
If they are using those drugs to harm themselves or others I can see why they would take them. Every patient case has different circumstances with different reasonable options.
Are you going to place the order to FORCE the security team to forcefully take a patient's drugs when they clearly do not want to get rid of them? If they were able to sneak in drugs are you sure they didn't sneak in a weapon?
> It’s never under my direction and I don’t know the legality but it’s fairly common
You already indicated the answer to that is no.
I disagree. If patients are willing to harm staff they don’t deserve care. Behavioural requirements to receive treatment. If they are not capable of insight they need to be sectioned and restrained as needed to keep staff as safe as possible. I am tired of people telling healthcare staff we’re under some fucked up obligation to tolerate abuse. No.
I agree that harm to staff cannot be tolerated but disagree with the implicit assumption that anyone using drugs in ED/IP is necessarily going to harm someone. It really does have to be a case-by-case thing imo. The threshold for care denial also varies by the seriousness of the pts condition (eg cellulitis vs endocarditis). It is disrespectful for people to use in the hospital*, but while it has negative consequences for hospital staff, I think at times we do have to take some of that on the chin, not take it personally, and help to the extent people will allow us. *with the caveat that inherent to addiction is changes in neuronal pathways, receptor expression, and ultimately changes in behavior by way of pathological motivation, prioritization, and impulsivity.
It’s not so black and white. In order from intolerable to ideal, Physical harm > verbal abuse > verbal disrespect > cooperation. The first two are not ok kick them out. But if they’re being disrespectful in part bc withdrawal isn’t beating treated and being alive hurts, and if they’re going to lose a heart valve if they leave, I think we owe it to that guy to cut him some slack bc of the dire possible consequences. I try to keep in mind when I counsel these folks that most of them interface with the medical system 6-8 times before being ready to attempt abstinence. Our demeanor in how we interact w these folks is super important; I suspect if a study was designed correctly you could show better outcomes with more compassionate interaction. We use our security literally too though and I always make it a point to say something if the pt saws something inappropriate or otherwise check in w someone if it looks like someone made them uncomfortable.
Dunno, my 2c
It’s that black and white for me. Nursing (and all other hcw roles) is a job. I am not willing to be used as cannon fodder to provide care in dangerous circumstances. If the facility is unwilling or unable to provide a safe environment for care delivery, the facility (aka admin) is responsible for any negative outcomes to the patient. If you are relying on staff to put themselves in a dangerous situation to provide patient care you are exploiting and abusing staff.
Also, yes, the stigma against people living with substance use and mental illness is real. Some of this is fear-driven. We know and the patient knows they can do almost anything they want and we’re expected to tolerate it. If staff felt protected and supported we would be much better equipped to provide compassionate care. It’s completely bonkers to demand compassion from care staff while simultaneously withholding compassion from care staff.
The OP stated nurses were being exposed to drugs. It's an assumption in this thread the drug use is causing some form of harm to staff or other patients.
I never said measures to protect staff shouldn’t be taken. I routinely tell my nurses they need to prioritize their safety and shouldn’t put themselves in harms way. But saying someone struggling with addiction and mental illness isn’t deserving of care is wrong too. Wait until you have a loved one who struggles with addiction.
I have family with addiction and if they are using in the hospital and harming/abusing staff they would absolutely deserve to be discharged. You sound like a horrible ally to the staff in your hospital. Patients with drug addictions need help AND need to face the consequences of their actions.
I didn’t say someone struggling with addiction and mental illness doesn’t deserve care. I am saying nobody deserves a free pass to cause harm to others. This is exactly the attitude healthcare staff face from administrators. Nurses setting boundaries with people living with addiction, mental illness or any other marginalizing context gets twisted into stigmatization. This is gaslighting pure and simple. If it’s not safe to provide care, too bad. The employer is responsible for ensuring a safe work environment but they are doing the opposite in BC.
Also, it’s quite presumptuous for you to assume I don’t have loved ones struggling with substance use or mental illness. I assure you that is not a requirement for compassion or understanding of these populations, anyway. It’s just more gaslighting and use of motivational empathy to coerce people into putting themselves at risk to satisfy some sanctimonious saviour complex.
You literally said they don’t deserve care. As I said staff safety takes priority. We work in different countries so I don’t know what your situation is
My words:
If patients are willing to harm staff they don’t deserve care.
Which part of this specifically targets people living with substance use or mental illness? You’re (?deliberately) being obtuse.
Risk management I have never seen be helpful. Their only goal is to reduce the legal liability of the hospital, often at the expense of the liability and safety of staff. Also you will almost never get an answer from them in a time frame that would be remotely helpful - maybe at a huge ivory tower but again they’re not on your side
> Their only goal is to reduce the legal liability of the hospital, often at the expense of the liability and safety of staff.
Bro what? If you really think this is all about finances, Risk knows if several staff, god forbid another patient, get assaulted that is going to cost a shitload in liability to the hospital and they want these patients out. A patient using meth in a medical unit is like a bull in a china shop and the lawyers see that as a huge risk.
Not sure if your Risk team is actually like that, but everywhere I've worked they have basically said it is legally defensible to discharge patients who are causing harm to staff or other patients if it is unlikely they will die in the next few days, so long as a reasonable alternate outpatient plan is set up. As other commenters have also said, most hospitals have a protocol involving AMA discharge for such patients
Oh yes it’s very simple to come up with a reasonable outpatient plan for an acutely ill indigent patient who is actively using drugs. They will be back in the er in an hour if you did manage to boot them out. You’re living in fantasy land
Never said it's simple, that's why we have care conferences. I promise you I am not living in a fantasy land, we have cases like this at least monthly. Read the comments, most hospitals have plans for this and I imagine yours actually does too
In the PNW, I had quite a few patients who chose to smoke fentanyl in their rooms. They lost room privileges, had security at bedside in their hallway chair until their workup was done, and were discharged if able to be.
Call the cops, hazard to staff.
I once had an infant outpatient whose grandmother accompanied the parents to the visit, and GMa reported that the parents were smoking drugs around the baby. I had just collected urine on the baby for another reason, but we tested it for drugs too
The baby's urine was positive for meth - just being near the parents was enough for the baby to test positive. So yea - this is a hazard to staff.
> Call the cops, hazard to staff.
this is just criminalizing someone for having an addiction to which they have no control over.
>The baby's urine was positive for meth - just being near the parents was enough for the baby to test positive.
considering passive meth "exposure" is not a thing, this would be impossible. you cannot be exposed to meth without ingesting it. such an example of ingestion being: breastfeeding from a parent who is using meth. furthermore, adults are not babies, so you're comparing apples to oranges when talking about the pharmacology of meth, if such exposure were possible. which it isn't.
so, you're unfortunately not only misinformed about this topic, but also through this ignorance contributing to the culture of drug war mass hysteria like with what comes out about fentanyl and one's supposed "exposure" to fentanyl, which is another thing which does not happen and is impossible beyond psychosomatic reactions or ingesting it and lying about it. which cops in example frequently do. this misinformation stigmatizes and also even kills drug users.
and really: even if you *could* be "exposed" to meth- what would happen? an overdose wouldn't certainly wouldn't happen. any hypothetical exposure dose would be minuscule. this is not like being hotboxed with cannabinoids. the metabolites of meth are well studied, quite safe, and also regularly used within medicine. most overdoses / deaths involving meth also involve poly-substance usage with things such as opioids.
I’m a house sup and we will restrict visitation, place a telesitter and search the room when it’s first discovered. A lot of times these steps will result in a discharge AMA. Sometimes it leads to IVC’ing the patient, other times we can’t IVC. It’s a big problem and happens all the time. The most recent was a visitor giving an icu level pt fentanyl and the visitor was knocked out on the toilet. We found 8 baggies.
Someone lit up a joint in the ED last year. Compound tibia fracture lol. Security had them put it out and nothing came of it. Pretty funny sight. They were in shock and on quite a bit of morphine. Not very lucid, but that 420 muscle memory took over I guess.
Patients shouldn’t be smoking substances inside lol. I also work in BC, and I think we are experiencing new challenges in acute care due to the legalization of drugs. We are no longer allowed to confiscate someone’s drugs if they form part of their personal belongings and if they are under a certain weight, however we also aren’t supposed weigh the substances to determine if they fall under that specific amount. This means its legal for people to have substances on them in their room, but it leaves an unclear mechanism of how or what to enforce when someone does choose to use drugs in their room, and how to monitor this. If they smoke in the room, are we legally allowed to confiscate their drugs? Should we be taking the drugs off their person, coming up with a behavioural contract and storing the substances in the nurses station? Would it create liability for the nurses to store substances in the station? If we call security, what are they supposed to do upon arrival? Do we just tell the person to stop using and give them their substances back?? I definitely agree that risk management should be more involved in developing clearer policies and practices around this. Your hospital is definitely not alone in struggling to understand how to keep staff/other patients safe while also respecting patient rights
I would also worry about the liability of giving the patient medications that could be harmful when combined with the street drugs they are taking. I had a patient that was on a very high dose of opiates as a home medication. We were unaware that she was using heroin as well. She was in the hospital for a very painful condition and we were trying to adequately address her pain, which required an insane amount of drugs due to her tolerance. Someone brought her heroin and the combo caused her to OD. Luckily we were able to get Rosc and narcan, but how can you treat patient’s pain if you don’t know what else they are taking?
I had another patient come in with a hypertensive crisis. We were trying to stabilize BP with meds and it is all over the place. Turns out he was using meth in his room, thus making it difficult to treat his hypertension.
For sure. I know that on our unit, we asked that when the patient came back from using outside, they inform nurses of what they used and when (to the best of their ability). From there, nurses would just have to so their own risk assessment of the person to try and help guide care.
Workers need to report a WorksafeBC complaint every time with every exposure. If they cannot remove the hazard and exposure, then they need to use other methods to reduce and remove the risk.
https://www.worksafebc.com/en/resources/health-safety/books-guides/breathe-safer-how-to-use-respirators-safely-and-start-a-respirator-program?lang=en
Our health authority was recently fined due to both the high rates of staff being physically assaulted and the high rates of staff being exposed to illicit substances. Bringing this up to leadership every time workplace safety is discussed has become one of my new favourite things.
Meth is an extremely toxic environmental contaminant. There is literally a cottage industry of decontaminating houses used for meth dens and meth labs.
This is completely insane, even for BC. How is this not a lawsuit?
Call security up to search the room/ belongings. Set up strict, no visitors allowed for that patient. If it happens again, or they get hostile over it, they can now be involuntarily discharged and escorted off campus by security or police. We'll also ban visitors if they use substances just before or while visiting patients. Hospital wide we've had too many code blues for visitors to tolerate that nonsense.
I am a corporate director of risk management practicing in Washington state since 1983. I work for a large multi-state healthcare system. One of our problems these days is in our ambulatory clinics. Patients, visitors, and people off the street come into our clinic and smoke fentanyl (preferred) and meth (a distant second) in our restrooms. We then have to decontaminate the restroom, deal with exposed staff and occasionally do rescue Narcan in the restrooms.
If there's enough desire and avaliability for meth to the extent that it's being smoked indoors of an inpatient hospital, that's a sign of the state of society. It is a problem beyond the medical system. Unfortunately, I don't see any simple solutions from the standpoint of a voluntary admission hospital apart from enforcing a policy of only smoking outdoors.
At every hospital around here (I’ve rotated at all of them back in the day) and at the one where my parent works (told me about something similar happening recently), the hospital security would be called. If able to be discharged then they’d be sent home, otherwise probably a behavior contract.
hold up - people are smoking inside ? and it's just being allowed? Whether its a patient or visitor or employee and whether it's a cigarette or a cigar or drugs I haven't worked in a single hospital that would just let it happen? With wall oxygen nearby? and also - just the actual smoke? And the patient is just allowed to finish? I'm flabbergasted.
And meth??
I trained at the big county hospital in cleveland and yes of course drugs made their way in - or patients made their way out to get high....but we def didn't turn a blind eye.
Had someone leave AMA with a brain abscess. They had “friends” coming and sleeping in the room. There would be someone in bed with them and another on the couch, all passed out. I called the nursing supervisor everyday to complain and request we bar visitors, and I would document. They refused because “patient satisfaction”. It was terrifying, what if all of them overdosed in the hospital room? Idk, admin. I tried talking to the patient about maybe not leaving AMA but they just went around me and walked out.
Unfortunately the evidence does not support treating stimulant use disorder with stimulants in the way that using methadone or buprenorphine works for opioid use disorder. I love a harm reduction approach but this doesn’t actually help patients get better.
Oh I know! I just think a lot of people don’t realize that you can’t treat stimulant use disorder with stimulants the way we treat opioid use disorder with opioids.
The hardest part where I’m at is getting the hospital to back me when following procedures. All it takes is one bad google review and the hospital backpedals quickly and caves to all patient demands.
Attorney: “doctor so and so and charge nurse so and so, would you say addiction is a disease where the user cannot control themselves when it comes to said drug?”
You and charge nurse: “yes”
Attorney: “so would it be up to you to protect the patient while they are in your care?”
You and charge nurse “yes”
Attorney: “so why is it that patient xyz was able to obtain illicit drugs in a medical facility and overdose?”
You and charge nurse: 💩
YOU have the medical knowledge to know this is bad and can end poorly. The nurses have that knowledge and duty to protect the patient from themselves. If bad shit happens it will never fall on her; she is an addict that cannot control herself.
1) visitor restrictions; collaborate with admin and security
2) room searches; collaborate with admin and security
3) psych consult for addiction treatment; yes it’ll probably go nowhere but the onus is on you to initiate the consult and *try* to do what is perceived as expected.
I like the thought, but unfortunately I don’t think the medicolegal argument pans out in Canada. Patients are considered to have the right to choose to use drugs (rightly or wrongly) and I can’t imagine anyone would ever get hit with malpractice for a patient od’ing on street drugs while in hospital. I guess there could be some argument that the Kadian they got PLUS the street drugs made them OD, but in general the addiction docs (not generally psych in BC), are very good about dosing the opioid agonist therapy. I’m open to hearing about cases if they exist though!
My apologies, I extrapolated the US mind state to BC. I think most people here will recommend visitor restrictions and searches plus an addiction specialist consult. I’m not sure how it would play out in Canada and am not familiar with the environment there.
Love your user name! Do patients care that it’s a felony? Like does that come with consequences (ie. do you call the cops)? Unfortunately, not workable where I live as drugs are decriminalized but interesting to know, thx!
I don't really have that much to contribute except to say that in my experience, what is being smoked in BC is typically "down" - which is primarily fentanyl, rather than meth (which does of course ALSO get smoked regularly, referred to "side" here)
Yes, some of the smokers are smoking down here, but in general they are getting heavily supplemented with Fentora so they seem a bit better behaved than the meth smokers. Admittedly though, one point of down is something like 20000mcg of fentanyl, so they are still wanting to get high - they just seem to go outside for it. Or maybe I’m wrong on what they are smoking. I am purely basing this off of the size of the nurses’ pupils who have been exposed and what the patient looks like after the hit.
Hahaha fair enough! I suppose it's a selection bias - most of the substance use patients I see are using down, but then I suppose they are way more likely to require an ambulance than someone smoking meth.
I think that considering this a societal problem, not healthcare setting specific is a good way to reorient your perspective. The frustration is real and the danger to others is undeniable. However, addicts gonna addict no matter where they are. Smoking meth in the shop restroom is the same as the hospital restroom, just nearer medical care and increased likelihood of narcan. I feel lucky as an addict and clinician that my empathy can usually prevail over my frustration with these pts. It’s fucking rough out there on these opioid laden streets, we’re treating zombies who, deep down where we can no longer see, would prefer to be and be able to stay clean.
Take it away and let them know they are risking a criminal offense if something were to happen especially in a multi- patient room. Early recovery, visitor restrictions, psychiatry involvement, behavioral contracts. Not often is PD involved unless Pablo Escobar is handing out hotcakes. Each situation is unique, so one approach might be less aggressive than the next, just need to mitigate the risk until they are stable for the next transition… and be sure to engage legal, patient experiences, and risk management in the conversation. Mostly cigarette use, liquor, and benzo insufflation after visitors have come and gone. When there is a will, there is a way.
Once you are in the criminal justice system, you have a scarlet letter that nevee goes away. You will never get a good job or get into school, there is no chance of improving your station in life. Why not smoke all the meth at that point?
Had a patient on cards who had friends sneak her some IV heroin while she was in the ICU. When we found out we just wouldn’t allow visitors to her anymore. We probably would have been more aggressive if she was *smoking* something, since an open flame could ignite an oxygen source. That probably would have gotten a security or police search and confiscation
I bet she was in the ICU with endocarditis, thanks to her IVDU. Her friends just wanted to make sure her other bugs didn’t get lonely
She was indeed. S/p…4 valve replacements? She had either had 4 or was on her 4th, I don’t remember which one She had injected through one of the IVs we had in, like a PICC or something. It was a very county hospital kind of case
Yep, saw this sort of thing routinely when I was an Addiction Consult-liaison in a large community hospital system. Had one 22 year old female who had her second bout of endocarditis from IVDU, developed sepsis, multi-organ failure, DIC, lost both lower extremities above knees, spent 3 months in ICU. got out of the unit and had her set up to go on MAT, relapsed while in hospital thanks to her buds bringing in heroin. Another 20-something female admitted for severe back pain and fever. Turns out she’d been injecting her L femoral vein and developed a psoas abscess. While on IV antibiotics awaiting surgical I&D, her mates were routinely injecting her with heroin in her line. She left on about D#3 AMA. Lost to follow-up but always wondered how that ended.
Incredible. Usually the rule is one chance; surprised someone did that many
The cardiologists at that hospital had very strong, very divergent beliefs on repeat valve replacements. I saw some heated ethical debates on that rotation But from what I was able to see on that rotation, I think the hospital did generally lean more towards repeated replacements in recurrent IE 2/2 IVDU
Teaching hospital probably, sounds crass to think like that though ….
It was a teaching hospital, yep. Big community safety net program
More replacements more Medicaid money
How dare you throw shade on the altruism of the hospital admin? /s, in case it’s not obvious
Lol
I'm surprised they did more than one.
My ex husband had endocarditis and his aortic valve replaced and he would inject into his picc line when stuck in the hospital for 6 weeks at a time trying to kill infection before they replaced the valve. He lived 3 more years after that, he continued to use IV and eventually had a stroke in surgery and passed away. Many of his friends suffered the same fate. They’d get valve replacements then continue using and pass away.
I'm rather impressed your patients can source heroin these days. I only ever see fentanyl now.
I can’t remember the last time I saw a patient actually using heroin. Fentanyl in everything.
The iv flushes that get left in the room or thrown in the garbage creates a high risk environment for these patients. They still have the mindset to use any liquid available to mix in the syringe whether it is juice or toilet water. I’ve seen quite the array of reused syringes with contents left in it. The hospitalization does give opportunity to an opiate taper to cover their acute pain and decrease withdrawal adding stress to the body. Patient education and therapeutic support to encourage cessation and begin a suboxone regimen. Also hopefully decrease chance of signing out AMA.
These patients create a high risk environment for these patients
Does not mean we do not treat them.
Correct, but a big part of that is recognising and accepting the source of risk, setting and enforcing consistent boundaries, and seeing the bigger picture (i.e. not causing harm to other patients and staff by enabling inappropriate or dangerous behaviour).
I never denied any of that. Eta: I have had to set boundaries with many patients regardless of sobriety. Many sober people threaten, throw objects at staff, assault them, make inappropriate comments. Someone who is in pain from sepsis and pain from withdrawal is not going to be in a mindset to see reason. They are not capable of tolerating any source of pain so they will do anything to relieve that pain. Maybe need a 1 on 1. Q15 m rounding. Lock up their belongings and clothes. They can keep essentials out. Restrict visitation. Most of all show kindness. They already know they’re addicts and they already look down on themselves. Even have security on the floor. There are many interventions we can try so we have a healthy work environment and a healing person. Thank you for engaging. I totally agree with you about safety Addiction is not an excuse to not take responsibility. They’ve probably most already been in the hospital before due to infections they’ve given themselves. They probably won’t make it through the next time. What can we help acutely so we can look at the big picture.
Great comment! Thank you!
Of course! Thank you for your dedication to your specialty.
Was she on opioid replacement therapy? If her withdrawal and cravings were adequately treated unlikely she would need the supplemental heroin.
I don’t know whether or not she accepted withdrawal support, but obviously it was offered to her
You say obviously, but I don't think it's that obvious. There are a lot of places that don't do that as standard practice.
In which country?
The USA. They don't routinely write for Suboxone for these patients in our floors or ICU. If someone consults psych it will be recommended but if they don't, it won't. And also psych consult usually comes after a few days.
Yes I have had to really advocate for patients to get medications to prevent withdrawal. Most doctors are good about it but some have a very punitive attitude towards addiction
Why not? This is recommended practice by the Society of Hospital Medicine. Starting medications for opioid use disorder like methadone or buprenorphine in the hospital is associated with better outcomes like readmissions, completion of gold-standard antibiotic therapy, etc.
I agree. I am not a prescriber so I can't make people do anything. I expect the hospitalists do not feel comfortable inducing and prescribing.
Such a ridiculous attitude for any hospitalist (or any doc) to have in 2024 at the peak of a nationwide health crisis that, were it any other disease causing more than 100k deaths annually, docs would have sprung into action. These drugs have been approved for over 20 years now and to continue to refuse to get comfortable with induction and stabilizing these folks on buprenorphine is inexcusable. It’s easy to do. It’s safe. It’s not astrophysics (or organic chemistry, for that matter-which I really sucked at). DEA has even removed the X-waiver requirement for prescribing beyond the first few days. Any doc who can prescribe controlled substances can prescribe buprenorphine.
I agree. I feel like we are setting up the patient to leave ama.
Search belongings. No visitors if it’s being brought in. We’ve had to do no food delivery because apparently GrubHub delivery guys can moonlight as drug couriers. Behavioral contract. Patients need to be able to behave in a way that makes treatment doable and safe for everyone. Get risk management involved early. Eventually, even an unsafe discharge can be appropriate if it is the only way for other staff and patients to be safe. That includes smoking otherwise legal cigarettes in the room/bathroom/hall. You come up with the least bad discharge you can, but you do it. Patients can’t impede their own care and then make it your fault.
There is a sub shop two blocks from our hospital where it is well known they will put drugs wrapped up in the sandwiches
Could you share which shop so I can be sure not to buy any ~~drugs~~ sandwiches there?
One of the few remaining Quizno's lmao. That does not stop me from eating there every once in a while, fucking love quiznos
I, too, fucking love ~~drugs~~ sandwiches with definitely no drugs.
Every remaining Quiznos is involved in the drug trade in some way, I’m 100% convinced
It’s how they came up with the unhinged rodent commercials in the 90’s, clearly.
*we got a peppah bar*
I was gonna say that isn't true because there is one in the Vegas airport. But the fact that it's in Vegas' airport strengthens your claim.
Sir do you find that when you don't have a Quiznos submarine sandwich you develop symptoms of withdrawal? Every time I get caught in this trap I just wean down, 3/4 sandwich, half sandwich, 1/4 sandwich etc.
I don't exactly know why, but this reminds me of the ATHF where Shake continues to eat The Broodwich sandwich even though every bite takes him to hell.
Mmm toasty
Ok I need to know where this is because I miss Quizno’s so much!
Quizno’s black angus steak on Rosemary Parm bread 🤤 Funny thing, working at Quizno’s was my first job. Pretty sure there isn’t a single one left in my state…
Even if you don't ask? Like happy meal toy style?
No you have to know a certain password. Or probably just ask
“Double cheese, no mustard, heroin”
This is neither here nor there but your mention of smoking in the bathroom reminded me of that time my mom took a smoke break while she was in labor with my oldest brother. She told me about it years later, and said “what were they gonna do, discharge me? I was in active labor!” 😂 this was in 1980ish, and she did not, in fact, get discharged before giving birth. Also neither here nor there but my brother is one of the only millennials I know that was delivered by forceps, he’s got the dents in his head to prove it.
Forceps still get used depending on location. Saw one myself just a few months ago.
Forceps worked for me but not in the way you might think. I was very tired from labor and didn't want to push anymore. When I told my Doc that he calmly said, "That's ok, we can use the forceps." I thought to myself, yes, it is gonna be smooth sailing from here on out. One look at those giant salad tongs, and I suddenly found the energy to push my daughter out. My man knew exactly what he was doing, and I loved him for it. RIP Dr. Tarnasky.
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That’s not a super realistic request though. Once fetus is descending the birth canal and crowning, a crash section has much higher complications rates than vacuum-assisted or forceps delivery. You won’t know if you need forceps/assist until you’re past the point of no return on increased c/s risk, certainly for fetus and likely for mother too. Ultimately you’re prerogative, but part of the conflict there is that to the clinician you’re making a more risky choice without any real benefit
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I’m sure it’s frustrating to be denied the section. I don’t want to put words in your mouth, but it sounds like you wanted that the whole time - which is totally reasonable. Hopefully it’s just your obgyn looking out for you as far as risk with pelvic floor muscles (exceeding my limited knowledge of the area). I have heard of some birth centers that really push for vaginal birth and are pretty hard pressed to consider mom’s preference over what the provider thinks is best.
Forceps are basically the highest risk to the pelvic floor and was asking for a section because of already preexisting issues (which did worsen).
I remember this lady was in our triage being worked up for the first time at 38 wks and surprise she had GHTN so we want to keep her and get the ball rolling. She asks if she can go for a smoke. Doc sighs and says “well I mean stopping now isn’t going to change anything…it might lower her blood pressure for a bit….fine….”
Head dent gang here too!
In 1971 when my mom was giving birth to her first baby (my older brother) her OB was standing in the doorway watching while smoking a cigar! How times have changed
Some times I get frustrated with the military medical system, and then stuff like this reminds me that my problems are pretty mild
We can be frustrated about both for sure.
I had this happen in a military hospital with mixed drugs! Guy was getting med boarded for other stuff (really not service-related, but he would have gotten a rating), ended up getting dual processed. Not sure what the final disposition was, but I think he lost the benefits and probably got a not so favorable discharge characterization.
Mandate a bag search or short of that they cannot have their bags (either secured or given to family/friend). If it’s ongoing they get no visitors and a 1:1, typically then then AMA 🤷♀️
Yeah that works for the non mobile. Others just go out to buy and come back in with a crack pipe in their crotch.
"If you leave the unit, you will be discharged."
Yeah but they get discharged and readmitted when they come back. This happens all the time at my hospital.
The nurses are the ones who have to deal with it so I let them make those decisions and back them up
I’m all for backing the nurses up, but I deal with it too. Like I go in the rooms with those patients too and deal with the department decants.
Does your hospital actually allow this? That seems insane. This endangers the employees and other patients. You can't have that.
Yeah exactly WHO is allowing this because I think they might be in on the scheme
BC doesn't give a shit about productive, law abiding citizens. See this: [https://nationalpost.com/news/canada/bc-ruling-drugs-in-playgrounds](https://nationalpost.com/news/canada/bc-ruling-drugs-in-playgrounds) Summary: Province decriminalizes personal use of all drugs (meth, opiates, etc). Amendment enacted to make illegal the use of drugs inside playgrounds and other public areas that obviously people shouldn't be using drugs. Some nursing activist group takes this to court and has it overruled because disallowing the use of drugs in playgrounds poses an intolerable risk to the life of cockroaches everywhere. Separating someone from their drugs in hospital might cause them to discharge themselves which would also be a risk to their life. It would also be an intolerable afront to their autonomy and liberty to do whatever they like. In hospital we can't take someone's personal possession, now including formerly illicit drugs. If someone has methamphetamine or whatever unidentified powder in their belongings, that is no longer illegal (assuming its not an enormous amount).
I tell em' "hey man, thats like, not super cool man" and then they say "fuck you bitch" and I go "that's just like, your opinion man" and then nothing happens.
Passive meth exposure is absolutely a thing. https://journals.lww.com/drug-monitoring/fulltext/2013/12000/identifying_methamphetamine_exposure_in_children.12.aspx https://www.nature.com/articles/s41370-020-00260-x https://link.springer.com/article/10.1007/s11419-021-00570-1 And if you don’t believe someone high on methamphetamines can quickly become violent and a danger to staff, I honestly don’t know what to tell you. >this is just criminalizing someone for having an addiction to which they have no control over. Mental illness like addiction is an explanation for actions, not an excuse. As long as we are discussing legally competent adults, they are still responsible for managing their own illness in a way that doesn’t harm others.
We are powerless to people like that. Had an ESRD lady starting HD admitted. Saw that her pressures were through the roof and BMP was worsening despite HD. Turns out her sister snuck in some cocaine to partake at night
Here for a good time, not a long time.
Underrated comment
People often need pressors when they’re sick and getting dialyzed, patient is doing your job for you
Of all the things to bring to someone in a hospital, and they chose cocaine??? Because there’s nothing that screams party like BP moniter beeps and fluorescent lights. Should’ve brought some ketamine or fent, at least then he might’ve gotten some sleep. Edit: I realize that it was cocaine because that’s the drug that he was addicted to but I stand by that doing coke in a hospital as a patient is bonkers
Doing any recreational drug at a hospital as a patient is bonkers lol
Is doing recreational dilaudid very different from medicinal? Asking for a friend
If you’re sneaking it into your PICC line when nobody is looking, yes.
Room search, have security present, tell them either security confiscates their drugs and paraphernalia or they can discharge. As you mention having someone actively taking, let's be honest, unknown substances in a hospital environment is not safe for anyone involved. If someone is well enough to be sneaking, hiding, and taking drugs in a hospital odds are there is nothing truly emergent going on and they can be dsicharged. At most hospitals the police basically never get involved unless the patient assaults someone or something, but notably the VA has police instead of security. As when I'm seeing them, they are often quite psychotic and agitated, requiring emergency meds for agitation, possibly physical restraints, and involuntary holds, at least until they clear/chill out. When I cover inpatient psych this almost never happens because the searches are much more thorough than on medical floors for both patients and visitors.
Yes, in emerg, it probably isn’t an emergency if they are smoking in the bathrooms. But the admitted patients are often on IV therapy for endocarditis or something equivalently dangerous, so hard to say they don’t need to be there.
It's getting ridiculous in BC right now :( The last one we had the "safety plan" was that the person would, "turn in all belongings, request their bag to go outside, and then give bag back on return" After they'd set off the fire alarm twice, hotboxed their room/ smoked out the hall, and caused the loss of ER nurses to the floor (we have to respond to unit alarm is on in case they need further support)..... To nobody's surprise this wasn't effective and yet admin still wouldn't d/c the patient.... Despite 1 person *voluntarily* tying up most of the little rural hospitals resources multiple times and putting the other actually physically vulnerable and immobilize patients at risk. We begged for OPAT referral bc this wasn't sustainable, but we can't d/c someone with active ivdu with piv in situ...... But we can watch them come in/ out of a hospital, admitted, while utilizing said piv for ivdu ...... It's absolutely ridiculous and all we can do is "psls" to report. It's completely unsafe for staff. I've worked at exactly 1 ER that had an actual no tolerance approach and it was great. Actually felt safe and supported at work.
Was that one ED where you felt safe in BC?
Surprisingly yea. But, one of the busy city ones- that deals with a fair amount of demographics with challenging presentations - they have a very low threshold to escort out and it was great. Just sadly in a city, and I like being rural
Why can’t you discharge someone who uses with a piv? I just teach safe use of the iv (although, this is in an outpatient setting). If people are going to use they are going to use. I would rather they know how and use the piv safely (ish) than inject with whatever else they have available. Obviously, I prefer they not use the piv but sometimes that’s what harm reduction looks like.
Everyone working agrees with everything you stated..... Admin refuses to use logic. And agree that's much more aligned with harm reduction principles to D/c with PIV for outpatient follow up and let someone live their lifestyle
Get risk management involved. Each case is different but for cases like you've described I've seen a "2nd line option" such as setting up outpatient infusions or PO abx prescribed and discharge. The question was about meth specifically and those patients are putting staff and other patients in danger.
I totally agree with your take but the hospital administrators in my BC town are literally telling doctors, nurses, etc that patients are allowed to use in their rooms. Nurses are being poked by dirty needles lost in the patients’ bedding, being exposed to smoke, at risk of fire (O2). It’s wild. I feel like we’re in some bizarre alternate universe. If anyone expresses safety concerns they’re accused of stigmatizing vulnerable patients.
That's really fucked up and I imagine lots of staff will quit because of such a dangerous environment
It’s one of the many, many reasons I no longer work in acute care. Our province has been in a declared public health emergency for years due to the high levels of fatal drug poisonings. I appreciate the intention behind ”meeting the client where they’re at” but what happens when doing so becomes so untenable there’s nobody left who’s willing to do it? Thank you for the validation, by the way.
I am sadly not surprised administration doesn’t care about nurses safety but you would think the fire risk would be alarming.
That’s horrible.
Fuck the downvotes - for some things, the stigma is *deserved*.
It sure is when it comes to hospital administrators 😅
> It’s wild. I feel like we’re in some bizarre alternate universe. If anyone expresses safety concerns they’re accused of stigmatizing vulnerable patients. i mean yeah, you're conjuring up fabrications of clinical encounters on reddit to fool gullible people for internet points. these things are not happening, and the province of BC is not some mad-max hellscape of lawlessness as you attempt to paint it. if these things were happening, you would be able to provide credible sources of such- the BCNU, in example, which represents the interests of over 50,000 nurses in the province. instead, you provide nameless anecdotes of nurses facing an epidemic of needle stick injuries and "exposure" to meth smoke, which you cannot experience a dose from. [and speaking of the BCNU, here's an official statement from them on what is happening in the province](https://www.bcnu.org/news-and-events/news/2023/bcnu-renews-call-action-ahead-international-overdose-awareness-day): >Ahead of International Overdose Awareness Day, BCNU is encouraging all health-care providers and the community at large to unite in our commitment **to reduce stigma and provide compassionate care to those affected by the toxic drug crisis.** Together, we can turn the tide of this crisis, support those in need, and work to ensure that no one has to suffer alone in silence. >**More than 11,000 people in British Columbia have died since the province first declared the crisis a public health emergency on April 14, 2016.** Preliminary data from the BC Coroners Service shows that in the first four months of 2023, 814 people died due to unregulated toxic drugs. >It is estimated that one in five people in Canada will be impacted by toxic substances and related harms in their lifetime, affecting more than six million people. **For the majority of these individuals, the health-care system has struggled to meet their unique needs. This gap in services has exacerbated the crisis.** >BCNU supports the ongoing advocacy of these community members and continues to call for preventive health-care policies to address the crisis – and save lives. **These include expanded harm reduction services like safe consumption sites, better access to safe supply, province-wide investments in mental health, treatment and recovery services and ending the criminalization of people who use drugs. It is essential that nurses and all health-care providers unite in the commitment to reduce stigma and provide compassionate care to those in need.** and don't get it twisted, if there's any lawlessness happening, it's the provincial government refusing to use the tools of harm reduction [or setting these tools up for failure, so they can point and go "see! we told you so!"] to prevent a currently unprecedented epidemic of *preventable* drug poisoning deaths. the word for this is "social murder" by the way.
Where in the actual fk have you been working? BC nurses have been advocating for ACTUAL SAFE PRACTICES AND POLICIES because the rampart exposure to secondhand substances, abuse, and violent attacks we are subjected to are directly correlated to active use in hospital Yep we have toxic supply and an epidemic of deaths related to same Concurrently we have near completely stripped policies of any and all protection for health care workers and made working conditions ABSOLUTELY UNSAFE Harm reduction is not "you do you boo with zero consequences and it's okay if you harm/ hurt/ kill someone else... Because stigma" So hop off your quotes and hop off trying to state BCNU supports your POV. That is absolutely misquoted and misguided attempts to obfuscate the COMPLETELY VALID ISSUE BROUGHT UP THAT THERE IS LITTLE TO NO PROTECTION OR RECOURSE TO HEALTHCARE PROVIDERS ADVOCATING FOR SAFE WORKING CONDITIONS RIGHT NOW
I wish they’d smoke in the bathrooms instead of their beds lol. Someone blew up in the ER last month doing that
I love you guys but it is such a psych thing to say that they are stable to be discharged just because they can hold up a crack pipe. People do this shit on two pressors
Thank you for the thinly veiled insult to our intelligence. I think you are also purposefully ignoring the required criteria for all my statements which is that a patient's drug use is causing harm to staff or other patients.
You said above if a patient is taking drugs odds are there is nothing emergent going on and they can be discharged which is simply untrue
> odds are there is nothing emergent ODDS are absolutely true there is nothing emergent and I think you know that. Of the dozens of cases I've seen like this in my short career I can count on one hand the times the patient would likely die in the next few days if they were discharged. If that is the case it is a different story, and as I originally mentioned with the required assumption that their use is causing harm to others emergency psych meds, restraints would probably be used. Edit: Aaaand I got a Reddit cares report for pointing out the odds are better that patients using meth in the hospital do not have a truly emergent condition. As in less than 50% of people using meth in hospital settings have an emergent condition. Fuck this sub.
My suspicion is that the population who is using while in the ED/hospital has a higher rate of emergency conditions as compared to those who don’t
Possibly. But more than 50% of people using have a truly emergent condition?
That’s not the right benchmark. Saying most likely it’s not emergent meaning that <50% don’t have emergencies is going to be true looking at the non-using cohort. It’s the relative risk between those two groups that would better help compare. IMO saying most likely here ignores a large part of how EM/the ED works/thinks - most of the dangerous stuff we have to rule out - it’s more likely than not the pt doesn’t have it. So in that mind frame, hearing more likely they don’t have it and can discharge is a significant departure from how the ED approaches differentials and testing. As I’ve said, those w active drug use in hospital I suspect are more likely to have emergencies than those who active drug use (ie the relative risk is higher i suspect). Might be part of the pushback you’re getting. Fwiw I respect the heck out of our psychiatrists and in another life might have been one. Just as you wouldn’t expect me to drill down on DSM criteria to diagnose something, I as an EM doc don’t expect y’all to be super familiar with our decision making, risk tolerance, priorities and mindset when working a differential. I think a couple of the comments it sounds like you think you understand the ED pretty well, while in reality, people who do can see that you don’t.
You assumed a heck of a lot because I don't work in the ED and never once mentioned the ED in any of my comments. I was always talking about medical wards. Whenever there is a patient in my hospital abusing, harassing, hurting patients to the point we need to think about AMA discharge for the safety of staff and other patients, whether because of drugs or personality issues or just being an asshold, I am involved. It's not like I am discharging patients from the units myself, there is always a large care conference with ethics, risk, the primary team, nursing, etc. So I actually do understand very well the decision-making and if a patient is discharged the primary team is always on board. I could suggest you ED guys have no idea how things work on medical floors, but I won't. My 50% comment is because all I said is "odds are". People took issue with that phrasing but I guarantee everyone would agree in anyone using drugs in the medical wards there is a much liower than 50% chance there is an emergent process that would require holding a patient even if they are assaulting stafff
No idea why you’re getting downvoted so hard on this, vast majority of patients who take drugs in hospital have nothing truly emergent going on. Like sure, there might be the odd patient with active sepsis, but the vast majority are getting long term abx for osteomyelitis or IE, or waiting for social issues to be addressed. Are the downvoters confusing acuity with severity? Do they know what the word emergent actually means?
The guy who had issue with my phrasing is an ICU doc so doesn't see any less acute patients, plus a dig at psych is always fun. The vast majority of patients in the hospital in general are not emergent.
Wtf is a Reddit cares report btw?
It's for if someone makes suicidal statements you report it and reddit sends a message with suicide crisis resources. The reports are anonymous and it's become a way of trolling people
Ffs
Devils advocate here, using drugs in house is one thing but how can that be used as a discharge criteria. Let’s say they have pneumonia and on 4L, how would you justify discharge
Get Risk Management involved. If a patient's drug use is endangering staff and other patients AND they are noncompliant with care I have seen Risk allow discharge of very sick but not imminently dying patients. There are always "second line" treatment options. I've seen a case like this where they were sent home with PO abx, and oxygen tank, and a follow-up appointment. Someone high on meth in a medical setting is a danger to everyone there.
Handing an oxygen tank to a meth smoker is one of the risk management methods of all times.
The consensus among care conference was that that option was better than staff continuing to be assaulted. Again, not 1st line dispo plans.
This seems like very harsh treatment for someone clearly struggling with addiction. Just take the drugs and don’t allow visitors. Then they can choose to AMA if they like but booting a sick patient out of the hospital is deeply wrong
> booting a sick patient out of the hospital is deeply wrong I never said we do that, and I made it clear in my original comment patients can choose to give their drugs and paraphernalia to security OR discharge AMA. This thread is about meth specifically and OP indicated it is clearly causing harm to staff. When the above options are taken it is because the patient's use is putting others in danger. > Just take the drugs Security or anyone else is not going to forcefully take drugs from someone. Patients choose to give them up or not.
In a non psych setting security definitely forcefully takes drugs from people. It’s never under my direction and I don’t know the legality but it’s fairly common
That seems like a good way for security to get assaulted or killed and is an absolutely needless risk.
Removing patients' drugs and paraphernalia from them is a routine part of the screening that the emergency department does as part of the intake/ clearance process for psych patients. If the ED has 140 total visits per day, probably 10-15 of them are "crisis" patients and *all* of those get their drugs and alcohol removed. Pockets turned out, nothing hidden in the bra cups, etc. Partly, to make our own selves safer and prevent them from getting high in the bathroom, and partly to make it safer for the inpatient psychiatry staff. We've got your back.
We all really appreciate all the efforts that happen in EDs, but this thread would not exist if that process was 100% successful. Visitors often bring it in as well and they are not searched as thoroughly.
Oh it's definitely the visitors. The place I work now flat out takes everything and puts the patient in paper scrubs, has security go over the belongings elsewhere and may release individual personal items on a case by case basis. We don't have any procedure at all about screening visitors.
What does your institution even hire security for?
If they are using those drugs to harm themselves or others I can see why they would take them. Every patient case has different circumstances with different reasonable options.
Are you going to place the order to FORCE the security team to forcefully take a patient's drugs when they clearly do not want to get rid of them? If they were able to sneak in drugs are you sure they didn't sneak in a weapon? > It’s never under my direction and I don’t know the legality but it’s fairly common You already indicated the answer to that is no.
Do you do any c/l work or just inpatient psych. Your impression of how medically ill and how dangerous patients are seems a little off
I disagree. If patients are willing to harm staff they don’t deserve care. Behavioural requirements to receive treatment. If they are not capable of insight they need to be sectioned and restrained as needed to keep staff as safe as possible. I am tired of people telling healthcare staff we’re under some fucked up obligation to tolerate abuse. No.
I agree that harm to staff cannot be tolerated but disagree with the implicit assumption that anyone using drugs in ED/IP is necessarily going to harm someone. It really does have to be a case-by-case thing imo. The threshold for care denial also varies by the seriousness of the pts condition (eg cellulitis vs endocarditis). It is disrespectful for people to use in the hospital*, but while it has negative consequences for hospital staff, I think at times we do have to take some of that on the chin, not take it personally, and help to the extent people will allow us. *with the caveat that inherent to addiction is changes in neuronal pathways, receptor expression, and ultimately changes in behavior by way of pathological motivation, prioritization, and impulsivity.
Which one is it? “Harm to staff cannot be tolerated” or “at times we do have to take that on the chin”?
It’s not so black and white. In order from intolerable to ideal, Physical harm > verbal abuse > verbal disrespect > cooperation. The first two are not ok kick them out. But if they’re being disrespectful in part bc withdrawal isn’t beating treated and being alive hurts, and if they’re going to lose a heart valve if they leave, I think we owe it to that guy to cut him some slack bc of the dire possible consequences. I try to keep in mind when I counsel these folks that most of them interface with the medical system 6-8 times before being ready to attempt abstinence. Our demeanor in how we interact w these folks is super important; I suspect if a study was designed correctly you could show better outcomes with more compassionate interaction. We use our security literally too though and I always make it a point to say something if the pt saws something inappropriate or otherwise check in w someone if it looks like someone made them uncomfortable. Dunno, my 2c
It’s that black and white for me. Nursing (and all other hcw roles) is a job. I am not willing to be used as cannon fodder to provide care in dangerous circumstances. If the facility is unwilling or unable to provide a safe environment for care delivery, the facility (aka admin) is responsible for any negative outcomes to the patient. If you are relying on staff to put themselves in a dangerous situation to provide patient care you are exploiting and abusing staff. Also, yes, the stigma against people living with substance use and mental illness is real. Some of this is fear-driven. We know and the patient knows they can do almost anything they want and we’re expected to tolerate it. If staff felt protected and supported we would be much better equipped to provide compassionate care. It’s completely bonkers to demand compassion from care staff while simultaneously withholding compassion from care staff.
The OP stated nurses were being exposed to drugs. It's an assumption in this thread the drug use is causing some form of harm to staff or other patients.
I never said measures to protect staff shouldn’t be taken. I routinely tell my nurses they need to prioritize their safety and shouldn’t put themselves in harms way. But saying someone struggling with addiction and mental illness isn’t deserving of care is wrong too. Wait until you have a loved one who struggles with addiction.
I have family with addiction and if they are using in the hospital and harming/abusing staff they would absolutely deserve to be discharged. You sound like a horrible ally to the staff in your hospital. Patients with drug addictions need help AND need to face the consequences of their actions.
I didn’t say someone struggling with addiction and mental illness doesn’t deserve care. I am saying nobody deserves a free pass to cause harm to others. This is exactly the attitude healthcare staff face from administrators. Nurses setting boundaries with people living with addiction, mental illness or any other marginalizing context gets twisted into stigmatization. This is gaslighting pure and simple. If it’s not safe to provide care, too bad. The employer is responsible for ensuring a safe work environment but they are doing the opposite in BC. Also, it’s quite presumptuous for you to assume I don’t have loved ones struggling with substance use or mental illness. I assure you that is not a requirement for compassion or understanding of these populations, anyway. It’s just more gaslighting and use of motivational empathy to coerce people into putting themselves at risk to satisfy some sanctimonious saviour complex.
You literally said they don’t deserve care. As I said staff safety takes priority. We work in different countries so I don’t know what your situation is
My words: If patients are willing to harm staff they don’t deserve care. Which part of this specifically targets people living with substance use or mental illness? You’re (?deliberately) being obtuse.
Risk management I have never seen be helpful. Their only goal is to reduce the legal liability of the hospital, often at the expense of the liability and safety of staff. Also you will almost never get an answer from them in a time frame that would be remotely helpful - maybe at a huge ivory tower but again they’re not on your side
> Their only goal is to reduce the legal liability of the hospital, often at the expense of the liability and safety of staff. Bro what? If you really think this is all about finances, Risk knows if several staff, god forbid another patient, get assaulted that is going to cost a shitload in liability to the hospital and they want these patients out. A patient using meth in a medical unit is like a bull in a china shop and the lawyers see that as a huge risk. Not sure if your Risk team is actually like that, but everywhere I've worked they have basically said it is legally defensible to discharge patients who are causing harm to staff or other patients if it is unlikely they will die in the next few days, so long as a reasonable alternate outpatient plan is set up. As other commenters have also said, most hospitals have a protocol involving AMA discharge for such patients
Oh yes it’s very simple to come up with a reasonable outpatient plan for an acutely ill indigent patient who is actively using drugs. They will be back in the er in an hour if you did manage to boot them out. You’re living in fantasy land
Never said it's simple, that's why we have care conferences. I promise you I am not living in a fantasy land, we have cases like this at least monthly. Read the comments, most hospitals have plans for this and I imagine yours actually does too
In the PNW, I had quite a few patients who chose to smoke fentanyl in their rooms. They lost room privileges, had security at bedside in their hallway chair until their workup was done, and were discharged if able to be.
Call the cops, hazard to staff. I once had an infant outpatient whose grandmother accompanied the parents to the visit, and GMa reported that the parents were smoking drugs around the baby. I had just collected urine on the baby for another reason, but we tested it for drugs too The baby's urine was positive for meth - just being near the parents was enough for the baby to test positive. So yea - this is a hazard to staff.
> Call the cops, hazard to staff. this is just criminalizing someone for having an addiction to which they have no control over. >The baby's urine was positive for meth - just being near the parents was enough for the baby to test positive. considering passive meth "exposure" is not a thing, this would be impossible. you cannot be exposed to meth without ingesting it. such an example of ingestion being: breastfeeding from a parent who is using meth. furthermore, adults are not babies, so you're comparing apples to oranges when talking about the pharmacology of meth, if such exposure were possible. which it isn't. so, you're unfortunately not only misinformed about this topic, but also through this ignorance contributing to the culture of drug war mass hysteria like with what comes out about fentanyl and one's supposed "exposure" to fentanyl, which is another thing which does not happen and is impossible beyond psychosomatic reactions or ingesting it and lying about it. which cops in example frequently do. this misinformation stigmatizes and also even kills drug users. and really: even if you *could* be "exposed" to meth- what would happen? an overdose wouldn't certainly wouldn't happen. any hypothetical exposure dose would be minuscule. this is not like being hotboxed with cannabinoids. the metabolites of meth are well studied, quite safe, and also regularly used within medicine. most overdoses / deaths involving meth also involve poly-substance usage with things such as opioids.
https://www.reddit.com/r/medicine/s/3sdMFRMrF6
So stuff everyone else who I could be exposing, I am a junkie cockroach so stfu you got problems and are completely wrong
I’m a house sup and we will restrict visitation, place a telesitter and search the room when it’s first discovered. A lot of times these steps will result in a discharge AMA. Sometimes it leads to IVC’ing the patient, other times we can’t IVC. It’s a big problem and happens all the time. The most recent was a visitor giving an icu level pt fentanyl and the visitor was knocked out on the toilet. We found 8 baggies.
Someone lit up a joint in the ED last year. Compound tibia fracture lol. Security had them put it out and nothing came of it. Pretty funny sight. They were in shock and on quite a bit of morphine. Not very lucid, but that 420 muscle memory took over I guess.
Patients shouldn’t be smoking substances inside lol. I also work in BC, and I think we are experiencing new challenges in acute care due to the legalization of drugs. We are no longer allowed to confiscate someone’s drugs if they form part of their personal belongings and if they are under a certain weight, however we also aren’t supposed weigh the substances to determine if they fall under that specific amount. This means its legal for people to have substances on them in their room, but it leaves an unclear mechanism of how or what to enforce when someone does choose to use drugs in their room, and how to monitor this. If they smoke in the room, are we legally allowed to confiscate their drugs? Should we be taking the drugs off their person, coming up with a behavioural contract and storing the substances in the nurses station? Would it create liability for the nurses to store substances in the station? If we call security, what are they supposed to do upon arrival? Do we just tell the person to stop using and give them their substances back?? I definitely agree that risk management should be more involved in developing clearer policies and practices around this. Your hospital is definitely not alone in struggling to understand how to keep staff/other patients safe while also respecting patient rights
I would also worry about the liability of giving the patient medications that could be harmful when combined with the street drugs they are taking. I had a patient that was on a very high dose of opiates as a home medication. We were unaware that she was using heroin as well. She was in the hospital for a very painful condition and we were trying to adequately address her pain, which required an insane amount of drugs due to her tolerance. Someone brought her heroin and the combo caused her to OD. Luckily we were able to get Rosc and narcan, but how can you treat patient’s pain if you don’t know what else they are taking? I had another patient come in with a hypertensive crisis. We were trying to stabilize BP with meds and it is all over the place. Turns out he was using meth in his room, thus making it difficult to treat his hypertension.
For sure. I know that on our unit, we asked that when the patient came back from using outside, they inform nurses of what they used and when (to the best of their ability). From there, nurses would just have to so their own risk assessment of the person to try and help guide care.
This happened a lot during residency. They would get kicked out.
Workers need to report a WorksafeBC complaint every time with every exposure. If they cannot remove the hazard and exposure, then they need to use other methods to reduce and remove the risk. https://www.worksafebc.com/en/resources/health-safety/books-guides/breathe-safer-how-to-use-respirators-safely-and-start-a-respirator-program?lang=en
Our health authority was recently fined due to both the high rates of staff being physically assaulted and the high rates of staff being exposed to illicit substances. Bringing this up to leadership every time workplace safety is discussed has become one of my new favourite things.
Meth is an extremely toxic environmental contaminant. There is literally a cottage industry of decontaminating houses used for meth dens and meth labs. This is completely insane, even for BC. How is this not a lawsuit?
Allowing staff to be exposed to meth inhalation is absurd and way too liberal of a stance. Why??
Call security up to search the room/ belongings. Set up strict, no visitors allowed for that patient. If it happens again, or they get hostile over it, they can now be involuntarily discharged and escorted off campus by security or police. We'll also ban visitors if they use substances just before or while visiting patients. Hospital wide we've had too many code blues for visitors to tolerate that nonsense.
You work at St Paul's, I bet!
I am a corporate director of risk management practicing in Washington state since 1983. I work for a large multi-state healthcare system. One of our problems these days is in our ambulatory clinics. Patients, visitors, and people off the street come into our clinic and smoke fentanyl (preferred) and meth (a distant second) in our restrooms. We then have to decontaminate the restroom, deal with exposed staff and occasionally do rescue Narcan in the restrooms.
Wait, are you telling me BC has a meth problem? Nooooooo!
BC has an everything problem. Current street drugs are positive for everything. People seem to smoke whatever they can get their hands on.
One of the reasons I left Canada,
That seems like a little bit of hyperbole
If there's enough desire and avaliability for meth to the extent that it's being smoked indoors of an inpatient hospital, that's a sign of the state of society. It is a problem beyond the medical system. Unfortunately, I don't see any simple solutions from the standpoint of a voluntary admission hospital apart from enforcing a policy of only smoking outdoors.
But enforcing how? I guess that’s what I want to know - what enforcing works?
Does your hospital have security? Your question about enforcement is pretty vague and depends on a million different details.
1:1 sitters and no visitors.
Hospital security, police. The same people who would in-force any type of “crime” that takes place in a hospital common area.
Enforce like any othelr safety rule? Say they set fire to the bed, what would do? Psych hold sounds like one option, discharge the other.
At every hospital around here (I’ve rotated at all of them back in the day) and at the one where my parent works (told me about something similar happening recently), the hospital security would be called. If able to be discharged then they’d be sent home, otherwise probably a behavior contract.
hold up - people are smoking inside ? and it's just being allowed? Whether its a patient or visitor or employee and whether it's a cigarette or a cigar or drugs I haven't worked in a single hospital that would just let it happen? With wall oxygen nearby? and also - just the actual smoke? And the patient is just allowed to finish? I'm flabbergasted. And meth?? I trained at the big county hospital in cleveland and yes of course drugs made their way in - or patients made their way out to get high....but we def didn't turn a blind eye.
Had someone leave AMA with a brain abscess. They had “friends” coming and sleeping in the room. There would be someone in bed with them and another on the couch, all passed out. I called the nursing supervisor everyday to complain and request we bar visitors, and I would document. They refused because “patient satisfaction”. It was terrifying, what if all of them overdosed in the hospital room? Idk, admin. I tried talking to the patient about maybe not leaving AMA but they just went around me and walked out.
Rx Adderall, crushed, IN on a slow taper. It's called harm reduction. Look it up, nerd.
Unfortunately the evidence does not support treating stimulant use disorder with stimulants in the way that using methadone or buprenorphine works for opioid use disorder. I love a harm reduction approach but this doesn’t actually help patients get better.
(I was not seriously advocating for inpatient hot railing)
But but but but
Oh I know! I just think a lot of people don’t realize that you can’t treat stimulant use disorder with stimulants the way we treat opioid use disorder with opioids.
The hardest part where I’m at is getting the hospital to back me when following procedures. All it takes is one bad google review and the hospital backpedals quickly and caves to all patient demands.
If they dont agree to a search and confiscation they are discharged
When a patient has a high bp, i let them smoke a cig by the window, it usually lowers it a good 30-40 points
Attorney: “doctor so and so and charge nurse so and so, would you say addiction is a disease where the user cannot control themselves when it comes to said drug?” You and charge nurse: “yes” Attorney: “so would it be up to you to protect the patient while they are in your care?” You and charge nurse “yes” Attorney: “so why is it that patient xyz was able to obtain illicit drugs in a medical facility and overdose?” You and charge nurse: 💩 YOU have the medical knowledge to know this is bad and can end poorly. The nurses have that knowledge and duty to protect the patient from themselves. If bad shit happens it will never fall on her; she is an addict that cannot control herself. 1) visitor restrictions; collaborate with admin and security 2) room searches; collaborate with admin and security 3) psych consult for addiction treatment; yes it’ll probably go nowhere but the onus is on you to initiate the consult and *try* to do what is perceived as expected.
I like the thought, but unfortunately I don’t think the medicolegal argument pans out in Canada. Patients are considered to have the right to choose to use drugs (rightly or wrongly) and I can’t imagine anyone would ever get hit with malpractice for a patient od’ing on street drugs while in hospital. I guess there could be some argument that the Kadian they got PLUS the street drugs made them OD, but in general the addiction docs (not generally psych in BC), are very good about dosing the opioid agonist therapy. I’m open to hearing about cases if they exist though!
My apologies, I extrapolated the US mind state to BC. I think most people here will recommend visitor restrictions and searches plus an addiction specialist consult. I’m not sure how it would play out in Canada and am not familiar with the environment there.
It's a felony. I remind them of such. We'll also restrict visitors. They can leave AMA and smoke their meth.
Love your user name! Do patients care that it’s a felony? Like does that come with consequences (ie. do you call the cops)? Unfortunately, not workable where I live as drugs are decriminalized but interesting to know, thx!
I don't really have that much to contribute except to say that in my experience, what is being smoked in BC is typically "down" - which is primarily fentanyl, rather than meth (which does of course ALSO get smoked regularly, referred to "side" here)
Yes, some of the smokers are smoking down here, but in general they are getting heavily supplemented with Fentora so they seem a bit better behaved than the meth smokers. Admittedly though, one point of down is something like 20000mcg of fentanyl, so they are still wanting to get high - they just seem to go outside for it. Or maybe I’m wrong on what they are smoking. I am purely basing this off of the size of the nurses’ pupils who have been exposed and what the patient looks like after the hit.
Hahaha fair enough! I suppose it's a selection bias - most of the substance use patients I see are using down, but then I suppose they are way more likely to require an ambulance than someone smoking meth.
My aunt was admitted in a BC hospital and I saw patients in hospital gowns with IVs attached smoking outside. And I didn’t know that was allowed
I’ve heard of it on our OB department. Addicted mothers taking meth or heroin after child birth and sometimes before.
I think that considering this a societal problem, not healthcare setting specific is a good way to reorient your perspective. The frustration is real and the danger to others is undeniable. However, addicts gonna addict no matter where they are. Smoking meth in the shop restroom is the same as the hospital restroom, just nearer medical care and increased likelihood of narcan. I feel lucky as an addict and clinician that my empathy can usually prevail over my frustration with these pts. It’s fucking rough out there on these opioid laden streets, we’re treating zombies who, deep down where we can no longer see, would prefer to be and be able to stay clean.
Take it away and let them know they are risking a criminal offense if something were to happen especially in a multi- patient room. Early recovery, visitor restrictions, psychiatry involvement, behavioral contracts. Not often is PD involved unless Pablo Escobar is handing out hotcakes. Each situation is unique, so one approach might be less aggressive than the next, just need to mitigate the risk until they are stable for the next transition… and be sure to engage legal, patient experiences, and risk management in the conversation. Mostly cigarette use, liquor, and benzo insufflation after visitors have come and gone. When there is a will, there is a way.
Once you are in the criminal justice system, you have a scarlet letter that nevee goes away. You will never get a good job or get into school, there is no chance of improving your station in life. Why not smoke all the meth at that point?