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1st chest #X-ray AP portable of a 37yo male with an 8yo personality admitted for excessive alcohol intoxication. History of previous treated PTB. Found unconscious at home then brought to ED/ER. Intubation was done then transported to ICU. Note the foreign body near cursor. Thoughts?

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Case Discussion

• We were dispatched to a 56 year old female with a history of Bipolar disorder & disassociate identity disorder, previously known as multiple personality disorder. The patient had supposedly inflicted self harm wounds to her wrist and neck with a knife according to the caller. The patient is in her home address.
• The patient sustained a 4 inch vertical laceration on her L wrist with quite significant adipose tissue exposure, as well as a superficial wound to her neck, in which she claims both were inflicted by her friend at the house. The patient has a significant history of self harm.
• The wounds were dressed appropriately and it was advised to the patient that she would require further wound closing management at hospital, in which the patient refused. The patient could demonstrate she had capacity through being GCS 15, had the ability to weigh up risks, retain the information given as well as verbalise it. This was consistent hours after the initial capacity assessment was made.
• A clinical advice line was contacted for further support on the matter. They deemed that because she has dissociative identity disorder and we do not know what personality she is displaying, that she lacks capacity based on the premise that she has a temporary or permanent disturbance of the mind. They also added that because the story was inconsistent & the most probable cause of the injuries was self harm, that it also supports that she lacks capacity.
• A second capacity assessment was undertaken after this phone call, where the patient was told that based on the advice given, that we do not believe she has capacity. The patient told the crew & police to give her a reason for why she doesn't have full capacity as she has answered all our questions. The patient stated that if we were to remove her out of the property without her consent that she will press charges.
• A decision was made between the crew and police to leave the patient in her home despite the obvious need for treatment. The police know the patient quite well and stated that she was showing no signs of an alternative personality. The crew and police also concluded that despite her history of self harm, we cannot speculate that her story is in fact false.
• Despite a decision being made, it is still a grey area whether it was the right one. My question is, what would you do and why? Do you believe this patient has capacity and what is your rational behind it?