The lesser of evils

Farrin A. Manian
St. Louis, Missouri, United States (Fall 2010)

 

“Staph infection” was the last consult of the night. Even before laying eyes on him, the nursing staff warned me that the patient, John, was already hinting about leaving the hospital no more than 24 hours after his admission. As I walked into his dimly lit hospital room, I found a young man in his 20’s lying in bed. He greeted me politely, but appeared anxious. After turning the lights on, I noticed that his body had served as a living canvas for a creative tattoo artist. Many cracks on his finger tips and palms were filled with grime so dark that even industrial strength detergent could not erase. But the most obvious finding was a swollen, very tender, red leg oozing a ravine of pus. Although John freely admitted to having used intravenous (IV) heroin in the past, he insisted that he had been “clean” for several weeks. As for his leg infection, he reported that it all started out as a pimple, denying skin popping.

John obviously needed IV antibiotic therapy and close monitoring in the hospital in case of a need for surgery. He politely agreed to remain in the hospital for a few days until his infection was under control. As I was walking out of his room, he thanked me profusely. I left his room quite confident that I had got my message across. However, less than 24 hours later, I received a telephone call that John was demanding to be discharged immediately because of a family emergency. I spoke to him on the telephone and advised against making such a rash decision. Eventually, he acquiesced: “Alright Doc, I will stay one more night, but tomorrow morning I am getting out.”

The following morning, John’s admission wound cultures were already growing Staphylococcus aureus, and his leg was only marginally improved. But it did not matter. “Doc, I have to get out of here,” John kept pressing me. The attending physician who had seen him earlier that day had already ruled out the possibility of letting him go home on IV antibiotic therapy and had begun preparing AMA (against medical advice) papers. After all, given his history of IV drug use, John could not be trusted to use his IV access only for the prescribed antibiotic, so the reasoning went. Admittedly, this is the same line of thinking I had also been taught and had diligently subscribed to for many years. “No IV lines for home antibiotic therapy for IV drug users” was the modus operandi.  But in recent years, the more I thought about this conundrum, the more I realized that the position of categorically withholding home IV antibiotic therapy from patients with a history of IV illicit drug use deserved further scrutiny.

My rationale for considering home IV antibiotic therapy even in illicit drug users is based on several premises. First, I am not sure that self-reported illicit drug users, such as John, are likely to use their medically-necessary IV access for self-injection of illicit drugs any more than those who use such drugs, but who do not divulge this information to their physicians. Second, as another one of my illicit drug using patients recently reminded me, a desperate IV drug user is as likely to use his IV access for illicit drugs as easily in the hospital as at home. Third, in the overall scheme of things, the treatment of an acute, potentially fatal, infection should trump more chronic, albeit still very important, concerns relating to substance abuse. Could I ever forgive myself for withholding an IV antibiotic from John if he became sicker or even died of his infection only because of the concern that I might temporarily fan the flames of his addiction? Lastly, haven’t we as a society decided that the problem of illicit drug use cannot be solved easily and, in many instances, can be made safer by the provision of sterile needles and syringes? Is providing a readily available IV line for medical reasons any more tempting for John than providing him with free sterile needles and syringes?

John might have wished to go home because he wanted to administer his feel-good substance in the friendly confines of his home. I also worried that by letting John go home with a secure IV line, I risked being held liable for providing him a ready means of administering a potentially fatal illicit drug. I was also not oblivious to the behavior I was positively reinforcing, potentially giving John an excuse for future hospital admissions that required extended courses of IV antibiotics. But I also realized that the practice of medicine is often not about finding the perfect solution to our patients’ ailments but about picking the lesser of the evils.

It didn’t matter. Despite my pleading with John to stay in the hospital, he insisted on leaving. “Well, John, I can try to set up home IV antibiotic therapy, but you have to promise me that you won’t use your IV for anything other than your medicine,” I proposed.

“No, Doc, I know better than that. I’ve got to take care of this infection,” he assured me.

“So, do we have a deal, John?” I asked.

“We have a deal!” he replied as we shook hands.

I was struck by his sincerity and honesty. After all, he had already freely admitted that he had been an IV drug user in the past, and the nurses had not reported any suspicious absences from his hospital room. So I decided to let John go home with a secure IV access. Before discharge, I asked John to return visit to my office in 10 days; he assured me he would.

Ten days passed, and John still had not made a follow-up appointment.  My office staff contacted him by telephone.  He said he had been very busy and simply forgot.  When he came to the office he was accompanied by his two small children and a pregnant wife or girlfriend of whom I knew very little of when he was still in the hospital. He introduced me to his family and remarked: “This is the cool doctor I was talking about.”  He said that his IV therapy at home had gone without a glitch. His leg showed no further signs of infection, and I was extremely happy with the outcome. After briefly watching him interact with his wife and kids in the exam room, I was convinced that John was the center of his family’s universe, and I could understand why he might have been needed at home. I convinced myself that I had done the right thing. John had followed all of my recommendations and turned out to be a model patient after all.

I then told John that because he had completed his antibiotic therapy, his IV catheter was no longer needed and that it was going to be removed.  As I prepared to remove his IV access, John turned his gaze toward the catheter and nervously asked “Can you leave it in for a couple more days, Doc?”  He gave no reasons, and I did not have to ask. “No, it may get infected John, and the last thing we need is another infection,” I replied as I removed the IV catheter.  I discarded it into the trash and dropped the lid on my fleeting euphoria.

 


 

FARRIN A. MANIAN, MD, MPH, FACP, FSHEA, FIDSA, received his Masters of Science in Public Health-Epidemiology and MD degrees from the University of Missouri-Columbia. He completed his residency in Internal Medicine and fellowship in Infectious Diseases at Vanderbilt University Medical School in Nashville.  He is a fellow of the American College of Physicians, Society of Healthcare Epidemiology of America, and Infectious Diseases Society of America.  He has authored or coauthored over 80 scientific articles and book chapters. He is the author of the book, Mosby’s Curbside Clinician: Infectious Diseases and was the first editor of APIC handbook of Infection Control.  He has been voted as one of America’s “Top Doctors” in Infectious Diseases.

 

Highlighted in Frontispiece Fall 2010 – Volume 2, Issue 3
Hektorama  | Doctors, Patients, and Diseases