As I watched the President board a ‘copter at Walter Reed, I was thinking about all the times I’ve seen people sign out of the hospital against medical advice. AMA is the acronym. In short, the docs said don’t go, the patient overruled them. He’s outta there.

Happens every day in every hospital I’ve ever heard of. Just more often if you’re working with addictions patients.

In this case a phalanx of physicians in white coats appeared before the press to explain, using extremely careful language, that the president was actually being released because he “met all standard hospital discharge criteria.”

What’s that mean? His insurance lapsed? they needed the bed? Sorry, couldn’t resist.

With some notable exceptions, AMAs follow a predictable pattern. Someone is admitted to the hospital in crisis. They’re treated for acute symptoms. But rather than completing the recommended course, they present at the nurse’s station with a demand that they must leave, and now. Invariably they provide some reason– a work deadline, an emergency in the home. Anything really, as long as it sounds appropriately urgent. I suppose sometimes it is, but often it’s an excuse for a premature exit.

One fellow explained that he was pretty sure he might have left some chili heating on the stove. There was nobody he could call to go look, therefore it was up to him. There was a good chance he made that up, of course. Stopped at the package store on the way home.

Just because something isn’t true doesn’t mean the person with an addiction hasn’t convinced themselves that it could be and therefore requires urgent action. There’s something known as covert craving, meaning it’s unrecognized as craving by the person who experiences it. But the accompanying anxiety or panic helps “sell” the AMA to the physician, who may even decide to give in and bless the discharge. As in, If I hadn’t written the order, he’d have left anyway. Why fight it?

I wonder if that was was the case at Walter Reed. We’ll never know for certain.

*          *          *

Some patients become repeaters: They enter the hospital later in the day, usually through the ER, spend a day or two (or less) in acute distress, then sign out AMA as soon as they can walk.

As you might imagine, these folks are not popular with the hospital staff.

One sticks in my memory: a man with more than forty previous admissions who presented at the elevator, bags packed. The head nurse was ready. She walked over, stood next to him. Held out a glossy magazine, which he accepted.

“This is a coffin catalog,” he said. She nodded. “I thought you might be needing that.” She walked back towards the nursing station.

I swear, steam came from his ears (never seen that before or since). “How DARE you”, he roared, followed by a string of invectives. Then the elevator arrived and he stormed out, still cursing.

Not long after, the letters began. Maybe a dozen or so, over the course of a few weeks, addressed to the hospital CEO, the Board Chair, Chief of the Medical Staff, Director of Nursing. All claiming he’d suffered extreme emotional and verbal abuse at the hands of this sadist who worked in Detox.

The CEO came to the unit to find out what the heck was going on.

“Look, he’s killing himself,” the nurse said, with a shrug. “Somebody had to tell him.”

Apparently no one else would.