The Case of Edgar Krill

From: Susan Aiworthy, M.D. Chief Resident, Emergency Medicine Service

To: Robert Stokemeister, M.D. Medical Director, Emergency Medicine Service

Bob,

I dictated this case summary last night, after another frustrating and time consuming encounter with Mr. Krill. I consider it a part of my job to promote promote empathy for street people in our residents and interns, but this particular individual makes this task exceedingly difficult. I have heard that the hospital administration and medical staff have agreed on a policy that allows us to refuse all but emergency life saving care in some rare circumstances, and I confess I have run out of other ideas. Does Mr. Krill fit this policy, and if not, can you explain to me what our obligations and alternatives are in this situation? Please let me know if other information would be helpful.

Edgar Krill is a 47 y/o male with a history of frequent Emergency Department visits over the past 18 months. Prior to the last 18 months, he was seen by the Emergency Department only occasionally for minor medical compaints and requests for pain medication. Currently, Mr. Krill visits to the Emergency Department at least once every 2 weeks and often with more frequency. The presenting complaints vary, but generally revolve around: intractable back and leg pain with attendants requests for pain medication, infected leg ulcers, and requests for mental health evaluation by the city police -usually following some form of public nuisance complaint, According to the police, Mr. Krill aggressively panhandles and often taunts and intimidates unescorted females. On 2 occasions over the past year Mr. Krill has been treated as the victim of a street assault, and each time he has blamed the police for beating him. He usual demeanor is loud, aggressive, and hostile -though there are a few staff he appears to cooperate with, at least for a time. During the last couple of Emergency Department visits, he has complained of difficulties in urination (e.g. "it takes me forever to piss, that's why the cops catch me at it") but he has refused a thorough examination.

Medical History Although Mr. Krill is not a reliable historian, his hospitalization on the neurological rehabilitation service 12 years ago provides an extensive medical history and social history. He had an unremarkable medical history until age 35, when he as hospitalized for closed head injury that resulted from a motorcycle accident. Mr. KnIl was intoxicated at the time, and according to the social work notes this was not unusual In addition, Mr. Kri1l apparently also had some convictions for "indecent liberties" and exposing himself, though the details on these offenses were not a part of the records available. At the time of his discharge from the rehabilitation unit, he was ambulatory but retained significant cognitive deficits in recent memory, judgment, and impulse control.

His prognosis for complete recovery was poor, both due to the extent of his injury and issues of motivation.

Social History Mr. Krill was graduated from high school at age 18 and following two years of military service was employed as a machinist. He married at age 22, but divorced within a year. The marriage produced one female child, but the time of his discharge from the rehabilatation service had no contact with his former wife and child. The only person in his life at that time was an older brother, Cliff, aged 37. Both parents were deceased, a mother due to breast cancer at age 31 and the father due to stroke at 57, Mr. Krill was unable to return to his former employment following his injury, and there is no record of employment or contact from family members since. He currently receives social security disability, sent general delivery to the Hall Street Post Office. According to the social work service record, he has no permanent address but knows to seek shelter when the weather is extreme.

Physical Examination. Limited, due to lack of patient cooperation. Mr. Krill is 5' 11'', weighs 230 points, is unwashed, unshaven, and rank smelling. His oral hygiene is also poor, and it is apparent that tooth decay and gum disease are far advanced. He takes no regular medication. He has several ulcerated skin lesions on both legs and edematous feet. His skin lesions look and smell infected. His pulse is 72, respirations 16, and B/P is 170/100. He complains of pain in his lower back but posture and flexation are unremarkable.

Current Problem Summary Mr. Krill presents a host of problems. His most serious physical problems are the ulcerous skin lesions, which are no doubt again infected. The typical course is for this condition to worsen to the point where an extended hospital admission is required (this appears to please Mr. Kri11 since social work notes indicate he consistently resists discharge). His infected teeth and gums are also a serious problem. His visits to the Emergency Department don't appear to provide much therapeutic benefit, are always disruptive, and his physical presentation and behavior frightens other patients and visitors. Since Mr. Krill consistently refuses appropriate examination and follow-up care, it has been suggested that he be refused service for all but emergency life- saving treatment. This particular visit he is being discharged with protective dressings, a topical antibiotic, dressing supplies, and written and oral instructions with the expectation he will return in a few days in a similar state.