Stand your ground, don't back down.
Sometimes you have no choice. Sure, you have to pick your fights, or you will just burn out. But sometimes you have to fight. You have to push, pull, coerce and convince. Sometimes it just ain't right that the patient stays another day. Case in point: a patient we admitted just the other day.
She was a trauma. Accident on the slopes. No major injuries, just some bumps and bruises. But the head CT showed a very small, questionable spot that might or might not be a head bleed. You know, such is the way Radiology covers their cans. "Likely nothing important, but cannot rule out blah, blah, blah." The medical speak of our modern, litigious society.
They saw it, which means we have to investigate it.
Neurosurgery is consulted. The morning after admission, the patient is fine, her confusion has cleared and realistically she needs to leave. But she is crying like a baby, demanding IV narcotics. I tell her she can have one dose, then will need to stick to oral stuff. We get the social worker involved because, honestly, the story is fishy and crazy. She will need a ride down to NY. There is no way I have the time and resources to work this out. God bless the social workers. Because she has so far to travel, and it is getting to be late in the afternoon, I tell her she can stay the night, but will leave in the morning.
Over night, she continues to demand IV narcotics. I have instructed nursing to absolutely refuse. In fact, her IV comes out. I walk in this morning and she is a mess. Begging for IV narcotics, acting confused, just playing it up. I tell her she will leave as soon as she has a ride. She throws up the wall of "But I have to know what is going on in my brain!"
I snap. A controlled snap, but a snap nonetheless.
"No you don't. You don't need to know because we can't know for sure. We can take pictures of your head, make our best guesses, but the only way to know for sure what is going on in there is to cut open your skull and remove a piece of your brain. Do you really want me to ask Neurosurgery to cut out part of your brain just to satisfy your curiosity?"
"I guess not," she replies sheepishly.
"Right answer." I walk out. I can't take it anymore. She is borderline personality disorder, no question. There is a reason Psychiatrists won't treat borderline patients. Push comes to shove, she balks, says she can't leave, but I have already written the discharge order. Nursing plays hardball. They call Security and Risk Management (aka the lawyers) and, yes, in fact, we can make her leave.
So leave she does. Against her will, but it is the right thing. Someone who is actually sick needs that bed, that nurse, and our attention. Not her.
Coercion. Sometimes you just have to push. And push hard.