Eloped!

Thomas Robey -- Medicine introduces a whole new language to medical students' vocabularies. Many of you would agree with me that learning a dictionary's worth of words is one of the hardest parts of medical education. Now in the midst of my language immersion experience, I've discovered a bonus of learning a new lexicon. Medicine not only invents new words -– it borrows them for its own use. My favorite of these new uses is the verb "elope."

To be fair, elope has two meanings in most online dictionaries. The first is the standard use regarding marriage. "Elopement to Las Vegas" puts one image in your head; "They eloped to save money," another; elopement in the context of parental disapproval yet another. There's a generic meaning of the word separate from matrimony, which is "to leave without permission or notification; escape."

Those of us who have worked on psychiatry wards or in emergency departments have learned this alternate definition. Let's say your floridly psychotic patient has responded well to the risperidone you've initially compelled her to take, then convinced her to take. Now she's asking you for the meds. (This is the story of my current psychiatry clerkship, by the way.) At our hospital, as patients progress to discharge, they can ask for increasing freedom. In my state, over the course of their stay, patients may transition from involuntary hold to a consented involuntary admission to a voluntary treatment. In parallel with this fluid legal status, patients may leave the locked floor escorted by staff (level 2), family (level 3), or other patients (level 4). This usually works out fine. On very rare occasions, however, patients are advanced a little too quickly. Someone on level 4 could encounter triggers on the outside. If, for example, your patient passes the corner across from the county hospital where crack is bought and sold, he may hatch a plan on his next level 4 release to leave the hospital and score a hit. Indeed this happened with one of my patients last week. I returned to work Monday to discover that the patient had actually only been admitted for 1.5 days, when I had been caring for him for about 10 days! It turns out he spent Friday night on a crack vacation, and checked back in on Saturday... What's the medical term for that? Elopement. Part of me thinks that the first physician to use the term had in mind some titillating scenario. I'll leave that question to the medical etymologists.

The psych ward isn't the only place I've heard the diagnosis of elopement. In the ED where I worked, next to the bins that say, "medicine," "surgery," and "peds" where you pick up new patients' charts, there's a bin labeled "LWBS." I didn't use this bin until I had a patient come in who had smoked a sherm. Unless you live in California, where PCP is accessible, most sherms are cigarettes dipped in embalming fluid (formaldehyde, etc.), and unlike the usually credible resource linked above, smoking (non-PCP) sherm is not usually "a lot like being totally drunk on acid and meth at once." In my experience (as an observer, of course!), smoking embalming fluid leads to verbal latency, paranoia and aphasia at best, and unresponsiveness, paralysis, and arrested breathing at worst. Perhaps the folks who get the "good" high stay away from the hospital. But I digress. Per the patient's history, he smoked a joint passed to him while watching a football game. He didn't know what was in this cigarette. He did remember waking up in an ambulance on the way to my favorite ED. I got his story, but he refused to let me put in an IV, draw labs or rehydrate him. He certainly did not permit a urine sample. He believed I was in cahoots with the cops, and when I returned with my attending, he was nowhere to be found. Hospital security pointed him out across the street (on the aforementioned crack corner, actually). I asked if he wanted care; he advised me to shred the documents associated with his stay. Instead, I dropped my note in the LWBS bin. My attending explained that he had eloped; medico-legally, this amounts to his having Left Without Being Seen (LWBS).

Whenever I learn a new meaning of an old word, I like to test out its use. Sometimes this verbal experimentation crashes and burns. Like how I got AMA and elopement confused for about two weeks. (In the ED, to leave AMA, the patient must sign a form indicating she understands her condition and the risks of leaving.) Other times, I'm quite happy with the outcome. As part of my psych clerkship, I take evening call in the psychiatry emergency services (PES) section of the ED. Nights in the PES are usually a trip, and it's a great place to see acute psychiatric problems. Last week it was slow. We had one patient who was clearly sick but was worked up in the first hour of my shift. All that was left to do for him by 8:00 was to write an affidavit for an involuntary hold, and wait for the county designated medical health professional to see him. With my final in a few weeks, I was anxious to use the downtime efficiently. Without a patient to see (and learn from) and without a quiet place to study, I was out of luck. Like the patient scheming his escape from the psych floor to score some crack, I was looking for any open door to bolt from the PES. Talk about empathizing with patients. As soon as the attending noticed I was not in a position to help the residents, she said, "you know, you don't have to stay until the..." Sometimes it's best to not let your supervisor finish that sentence. When I called my wife to see if she could pick me up, I excitedly told her I had eloped from the PES and needed a quick getaway.