The Case

A 50-year-old unhoused man (with no known family members or caregivers) presented to the Emergency Department (ED) at 0900 for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. He described a desire to consume metal, but he denied nausea, vomiting, diarrhea, or constipation. He also denied suicidal ideation or any intent to harm himself. His past medical and psychiatric history was notable for schizoaffective disorder and multiple prior foreign body ingestions (e.g., wrapped razors, pens, screws) with surgical scars from previous abdominal operations after these ingestions. He was taking no medications at presentation and had been lost from psychiatric follow-up care.

On physical examination, vital signs were stable, and his abdomen was soft and non-tender. Imaging revealed multiple metallic foreign bodies throughout the gastrointestinal tract including an open safety pin or paper clip in the distal stomach, a screw in the cecum, and a paper clip in the rectum. There was no free air or other signs of perforation. Psychiatric Emergency Services (PES) evaluated the patient and suspected schizophrenia versus bipolar disorder, with cluster B personality traits. Because he was not medically cleared, PES discontinued their consultation and offered no further recommendations, pending resolution of his medical issues.

Given concern for a sharp foreign body in the stomach, emergent upper gastrointestinal (GI) endoscopy within 2 to 6 hours, with anesthesia support, was planned. An order to keep the patient NPO (“nil per os” or “nothing by mouth”) was placed in the electronic health record (EHR) at 1030. However, this order was not communicated verbally, and the assigned nurse did not know that patient was NPO; therefore, she allowed the patient to eat before noon. When gastrointestinal endoscopy staff called the assigned nurse for hand-off and checklist review, it was recognized that the patient had just eaten. Anesthesia recommended to delay the procedure by several hours, and to perform it with endotracheal intubation to reduce the risk of aspiration. By the time endoscopy occurred at 1630, the sharp object had passed distally and could not be endoscopically visualized or removed. A subsequent x-ray confirmed no foreign body in the gastric area, so the patient was observed for signs of perforation and given laxatives to assist with bowel flush. He defecated but refused to show his fecal material to ED staff. After several hours of observation, the patient denied abdominal pain and left against medical advice, with a laxative prescription but no psychiatric follow-up.

The Commentary

by Christian Bohringer MBBS, James Bourgeois OD MD, Glen Xiong MD, and Emily Wei MD

Clinical Background

The 50-year-old unhoused patient in this case presented to the ED for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (to reduce the risk of aspirating gastric contents). However, the order was not known to all hospital staff, and it was not followed, leading to postponement of the procedure and ultimately to an unsatisfactory conclusion with discharge of the patient against medical advice. This case raises interesting questions about the evaluation and treatment of pica in the ED, the communication of dietary status information, the risks of procedural sedation in a non-fasting patient, and the evaluation of decisional capacity in a patient with recurrent pica.

Pica

Pica is a medical term describing the condition of eating non-digestible substances for more than a month, often in a habitual, compulsive manner. The term originates from the Latin word for the magpie bird which allegedly eats indiscriminately whatever it finds.¹ Pica is often associated with iron deficiency and therefore occurs more often in pregnant women and adolescents.² Iron replacement stops the craving for non-nutritive substances in the majority of reports, but not all.

Intentional foreign body ingestion occurs most often in children under three years of age. In adults, repeated intentional ingestion of metal objects usually occurs in patients with borderline personality disorder, bipolar disorder, or substance use disorders.^3,4 It is also common in prisoners who use the hospital admission and the endoscopy procedure as a means to break up the monotony of incarcerated life.⁵ Commonly ingested objects include knives, pens, razor blades, and batteries.⁶

Ingesting sharp metal objects risks perforation of the gastrointestinal tract, which may lead to bleeding, peritonitis and septic shock.⁷ Bowel obstruction from adhesions may be a late complication if the perforation remains unrecognized and untreated. Button style batteries that include lithium are especially likely to erode the gastrointestinal tract.^8,9 Esophageal burns from ingested button batteries can occur in as little as 30 minutes; necrosis can progress to erosion of the esophagus and adjacent mediastinal structures. Esophageal button batteries should be removed within 2 hours of ingestion (with very limited exceptions).

Most ingested foreign bodies pass spontaneously. However, sharp objects likely to perforate the gut and objects likely to cause bowel obstruction are typically retrieved by endoscopy if the ingestion was recent and the foreign body is still within reach of the endoscope. About 15% of patients require endoscopic retrieval and about 1% require a laparotomy to address complications such as bowel perforation or obstruction.¹²

Psychiatric comorbidities

From a psychiatric diagnostic viewpoint, it was important for the team to consider potentially comorbid conditions. For example, patients with factitious disorder consciously and manipulatively (usually surreptitiously) produce illness or injury fraudulently, for the express purpose of “obtaining patienthood”, often acting out needs for dependency. Less likely in this patient’s case, malingering is the conscious and fraudulent production or report of symptoms for clear external reward (e.g., legal compensation, pension) or to avoid an unpleasant circumstance (e.g., leaving prison, avoiding work or legal obligation). In patients with recurrent pica, personality disorders are often commingled with factitious disorder (e.g., borderline personality disorder, as in this case) or malingering (e.g., antisocial personality disorder).

Pica with sharp metal objects may represent a suicide attempt (e.g., in major depressive disorder) if the patient’s intent was death, or it can occur in response to a psychotic symptom (e.g., in schizophrenia or schizoaffective disorder) wherein patients cause self-harm as directed by a hallucination or delusion.^13,14 Swallowing of foreign objects is not per se a “suicide attempt” unless the motivation for the ingestion was death, but affected patients are prone to other, impulsive acts of self-harm.

This patient was assessed in the ED by a social worker from Psychiatric Emergency Services, but it is likely that he could not be detained on a psychiatric hold because he denied suicidal ideation or intended self-harm. The patient’s disposition was not an issue at that time, as he was undergoing evaluation and treatment for the medical consequences of his ingestion. However, after the endoscopic procedure, a separate psychiatric consultation should have been obtained to assess his symptoms and his decisional capacity, and to start medications targeted to schizoaffective disorder. Although psychiatric intervention may not prevent all further foreign body ingestions in this patient, it would have been appropriate to start medications and arrange outpatient follow-up. Other considerations should have included acute psychiatric hospitalization and subacute and long-term residential rehabilitation.¹⁵ Given the risk of recurrent foreign body ingestion, constant behavioral observation may be helpful until a sustained period of no impulsive behavior (on pharmacologic therapy) is observed and documented.

Procedural sedation and risk of aspiration

Esophagogastroduodenoscopy (EGD) is the procedure of choice to retrieve a recently ingested foreign body from the esophagus, the stomach or the first part of the small intestine. This procedure requires a combination of topical local anesthesia to suppress the gag reflex as well as pharmacological sedation for the patient to tolerate insertion of the large bore endoscope. Without adequate sedation, patients often gag and pull the endoscope out of the stomach.

Sedative drugs unfortunately increase the risk of aspirating regurgitated stomach contents into the lungs during or after a procedure. The American Society of Anesthesiologists (ASA) therefore recommends a fasting period of at least 6 hours for solid food (and nonhuman milk), and 2 hours for clear liquids, before sedation for elective procedures.¹⁶ The ASA acknowledges that “the literature in insufficient to evaluate the timing of ingestion of solids... and the perioperative incidence of pulmonary aspiration or emesis/reflux,” but it also says that “additional fasting time (e.g., 8 or more hours) may be needed in cases of patient intake of fried foods, fatty foods, or meat.”

Upper esophageal endoscopy was reported as the single most important risk factor for pulmonary aspiration during procedural sedation in a comprehensive systematic review.^17,18 The authors of this review found 292 instances of aspiration during upper gastrointestinal endoscopy, and only 34 during other procedures.

When the procedure is urgent, it cannot be delayed to allow for the recommended six-hour fasting period. The patient’s trachea is then usually intubated with a rapid sequence induction to reduce the risk of aspiration.¹⁹ With a rapid sequence induction, general anesthesia and neuromuscular paralysis are established quickly. The trachea is intubated without first ventilating the patient via a face mask. Avoiding face mask ventilation prevents blowing regurgitated stomach contents from the oropharynx into the lungs. The need for routine cricoid pressure during rapid sequence induction has been questioned but it is still advocated by most experienced practitioners.²⁰ Applying cricoid pressure compresses the esophagus and is intended to prevent passive reflux of gastric contents into the oropharynx.

For a case of endoscopic foreign body retrieval like this one, many operating teams prefer endotracheal intubation to procedural sedation alone because it reduces the risk of accidentally dropping the foreign body into the trachea after retrieving it from the stomach. The rapid-sequence approach to intubation is quite effective at preventing aspiration in high-risk patients. Perhaps for this reason, as well as careful intraprocedural monitoring, non-compliance with fasting guidelines has not been identified as a risk factor for aspiration in the literature.^18,21

The duration of fasting required for emptying the stomach varies according to the type of food, the patient’s gastrointestinal function, the administration of drugs that slow gastric emptying (e.g., opioids), and the patient’s underlying illness. In addition, the stomach continues to secrete acidic fluid while the patient is fasting, so there is no guarantee that the stomach will be empty during procedural sedation even when the ASA’s fasting guidelines are followed. Patients presenting with a bowel obstruction always require a rapid sequence induction irrespective of the time since their last meal.

Whenever the recommended fasting interval has not elapsed, the physician performing the procedure needs to confer with the anesthesia care provider to determine whether the urgency of the intervention outweighs the increased risk of aspiration. This risk-benefit assessment needs to be performed individually based on the specific clinical situation. A detailed history of the timing of the ingestion and the nature of the foreign body is important, as sharp metal objects that are likely to perforate the gut must be retrieved urgently. The duration of fasting, the type of food and any opioids given all need to be taken into consideration. Opioid medications significantly slow gastric emptying and are strongly associated with aspiration events.²²

A genuine surgical emergency always takes precedence over a full stomach. In this situation, the anesthesia team should use rapid sequence induction to avoid delaying a truly emergent procedure. Following the rapid sequence induction, the stomach should be emptied as much as possible because many aspiration events occur in the recovery room after the end of the procedure.²³ During a gastroduodenoscopy, the large bore endoscope can be used to irrigate and empty the stomach under direct vision much better than would be possible via an orogastric tube.

In EDs, nurses and physicians typically care for several patients at the same time, with frequent handoffs as patients go for imaging studies and then return for further treatment in the ED. Important information can be lost during these handoffs and shift changes. The hectic nature of the ED environment increases the risk for communication errors. For this reason, clinicians should take meticulous care to prevent critical information from being omitted during the handoffs. A formal handoff at the bedside has been recommended as a way to prevent the loss of vital information while better engaging the patient and family.^24,25

Approaches to Improving Patient Safety

Clear communication among staff

The physician in this case did not communicate directly via a face-to-face interaction with the nurse that an endoscopy was planned and that the patient needed to remain NPO for this procedure. Direct face-to-face communication remains the gold standard for handing over information because it allows the listener to confirm immediately that the message has been received, and to respond immediately to any questions. When entering information in the electronic health record (EHR) without this direct face-to-face feedback, there is no guarantee that the message will be read by the intended recipients in time to prevent an important dietary error.

When a new nurse is assuming care at shift change or break time, it is prudent for the physician to confirm that the new team member is also aware that a procedure is planned for the patient. Explaining the same plan repeatedly to fresh staff may seem exhausting, but this process should not be regarded as superfluous because it ensures that all current team members remain aware of the plan. Whenever a change is made in the plan, the communication process needs to start over again.

Communication from one nurse to another is also very important when handing over patient care. A formal handover process using a check list can be helpful. Implementation of a formal handoff program has been associated with a reduction in medical errors and preventable adverse events, improving communication without negatively affecting workflow.²⁶ Checklists should be used primarily as a memory aid to ensure that important things are not forgotten. When staff are pressured for time, however, they may go over the check list without actively processing the information. To avoid such “information overload,” clinicians should spend a few moments actively reflecting about which information is truly essential for their patient before starting the handoff. Transferring information efficiently requires practice; it has been proposed that clinical handover skills should be taught formally in educational institutions.²⁷

Hanging an “NPO” or “Nothing by Mouth” sign over the patient’s bed

A sign clearly indicating the requirement for fasting should be displayed prominently at the patient’s bedside so that it can be easily noticed by everyone, including staff delivering food and other persons who may not have access to the EHR. Patients often eat something given to them by a visitor unaware of their NPO status. ED patients may be confused and disoriented and therefore ask for food even when they are supposed to be fasting.

Put an “NPO” or “Nothing by Mouth” wristband on the patient

When patients are mobile, they often move around the hospital instead of staying near their bed. Sometimes they go to the cafeteria and try to get something to eat there, especially if they are confused, disoriented, or deliberately attempting to delay a procedure. Wearing a wrist band can therefore help to keep patients fasted because it alerts cafeteria staff to their NPO status. This identifier is especially useful for confused and disoriented patients.

Determine the urgency of the procedure

If the endoscopic procedure in this case had been deemed emergent, the anesthesia care provider would have proceeded with a rapid-sequence induction. If the patient then aspirated food into his lungs, the hospital and provider might have been regarded as negligent because the patient was fed after it had been determined that an endoscopy would be necessary. This liability issue may have led the physicians in this case to delay the procedure, instead of proceeding with rapid-sequence induction, as they might have done if the patient had eaten at home just before coming to the hospital.

Test the patient for iron deficiency

This patient should have been tested for iron deficiency. If his iron levels were found to be low, he should have been prescribed iron tablets or offered an intravenous iron infusion. The literature confirms that correcting iron deficiency frequently stops the craving for non-digestible objects.^28,29 Adherence with oral therapy may be an issue for unhoused patients, but this is not a reason to withhold medically indicated testing or pharmacologic therapy. If iron deficiency anemia is confirmed, then further diagnostic testing to identify the source of presumptive bleeding, such as colonoscopy, would be appropriate.

Assess Decisional Capacity

Decisional capacity for EGD was an important consideration in this case. Even patients detained on a psychiatric commitment order (which was not the case here) do not necessarily lack decisional capacity for an invasive GI procedure, providing that they have adequate understanding, appreciation, rationality, and communication of a consistent choice re the proposed procedure. In cases where this is unclear, formal cognitive assessment may be needed, as cognitive disorders are the psychiatric illness group most likely to correlate with impaired decisional capacity.³⁰

The decision to leave against medical advice is distinct from the capacity for informed consent for an invasive procedure. The request to leave the hospital against medical advice is often attributable to social problems in addition to psychiatric illness. The determination of capacity for AMA discharge and self-determination is also called dispositional capacity. As part of this process, adequate self-care behaviors should be demonstrated through in vivo dynamic assessment.³⁰

Conclusion

This patient probably did not suffer any harm as a result of this communication error because the foreign body likely traversed the gastrointestinal tract without injury. Looking after unhoused patients with mental illness is a particular challenge. Clear communication among all staff members is essential in the hectic high-stakes environment of the ED. The NPO status needs to be displayed prominently at the patient’s bedside as well as highlighted in the EHR. This patient is very likely to present again with further ingestions in the future because his underlying psychiatric comorbidities were not addressed.

Take Home Points

• Direct face-to-face communication between staff remains the gold standard, especially in high-risk settings such as the ED.
• Checklists can be helpful during handoffs.
• An NPO or “Nothing by Mouth” sign should be prominently displayed at the bedside, and a wristband can also be used for cognitively impaired patients who may walk to the cafeteria.
• The “Nothing by Mouth” (NPO) status needs to be highlighted in the EHR
• Urgent procedures do not require a fasting period, as rapid-sequence induction of endotracheal anesthesia is usually a safe and effective alternative.
• Patients with pica should be tested for iron deficiency and evaluated and treated for psychiatric comorbidities.

Christian Bohringer, MBBS
Professor of Anesthesiology
Department of Anesthesiology and Pain Medicine
UC Davis Health
chbohringer@ucdavis.edu

Emily Wei, MD
Resident
Department of Anesthesiology and Pain Medicine
UC Davis Health
ewwei@ucdavis.edu

James Bourgeois, OD, MD
Professor of Psychiatry
Department of Psychiatry and Behavioral Sciences
UC Davis Health
jbourgeois@ucdavis.edu

Glen Xiong, MD
Associate Professor of Psychiatry
Department of Psychiatry and Behavioral Sciences
gxiong@ucdavis.edu

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