Last week down in the ED, we consulted on a 40-something gentleman who had been smacked with a baseball bat and had a goose-egg so big it looked as though he was working on a second head. His initial CT scan was negative (well, as negative as it can be with a depressed, nondisplaced skull fracture). We wanted another one in the morning, after he chilled out in the step-down unit. He was advocating for the position that he get back outside and go about his business. The one thing he'd said that made any sense was that we should call his emergency contact, his mom.
Signing out AMA is no big deal, so long as you're competent to do so -- which is a legal question, and one we don't want to get into. We're concerned more with the medical question of whether you have capacity to make the decision. (If you don't see the distinction, then you're probably a normal person, and not someone who could be called to a courtroom to talk about something somebody else said or did several years ago.) If you're drunk or high, it's an easy call to make. If you're calm, reasonable, can count backward by sevens, and remember what you had for lunch yesterday, it's likewise pretty easy.
If you're acting like a tool, you're a little drunk, and you've been hit in the head recently, the way you're acting could be due to any possible combination of columns A, B, and C. So that's a little trickier.
The ER folks, with the patient's mom in agreement, decided that holding this guy against his will, for his own good, was the way to go. He naturally disagreed. So what I learned, and what I'm taking credit for naming here, was something I'll call Febrifuge's Equation.
I'll have to work out the specifics, but on one side we have all the factors that identify a person as medically obnoxious, and increasingly potentially dangerous to self or others: their blood alcohol level expressed as a percentage by volume, their body weight in kilograms, the number of security personnel needed standing around their gurney to approach an equilibrium. On the other side of the equation, balancing everything out nicely in this guy's case: his mom.
The equation would have to work such that "mom" (M) comes out to either a positive or a negative value. So long as M is a positive number, the person is able to be persuaded to stick with the plan. The values on the other side of the equation can adjust downward so long as M is still enough -- the number of guards can be reduced; with time the ETOH level will decrease; and everything will stay cool. But if M becomes a negative number, then not even the patient's mom can help. This is when things get tricky.