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Hurry Home

 

First of all, I’m having blog withdrawals. Seriously. I wish I could make a living writing a blog. It would be my dream job to write blog posts and troll the internet. Maybe some day.

So a quick story before I go to bed for another long day tomorrow.

At one of the hospitals where I moonlight, many nursing homes refer patients to the emergency department for routine medical care. Stuff like “patient has a rash for a week” or “patient is agitated.” Normally, it doesn’t bother me too much, but one specific nursing home not only sends its patients in for routine medical issues, but it refuses to take the patient back unless we do the testing that their nurses want. If a patient with a history of agitation gets sent in for agitation but arrives calm, we can’t just send them back on the same ambulance. We have to do tests … special “agitation” tests … to rule out excess agitation levels, apparently. Rashes have to have skin scrapings sent. Patients found on the floor must have head and neck CTs. Haven’t had a positive one yet, but try sending a patient back without one and the ambulance will be sent back to the ED. I tried fighting it a couple of times. They’d send the patient back. I’d do another exam while the patient was on the ambulance stretcher, take vital signs, then send the patient back again. Then there would be the call from their medical director to our department chair. Bad doctor. How dare we practice proper medical care? Patient returns by ambulance for third time. Just do the friggin tests, OK?

So when patients come with orders … er, um … requests … from this nursing home’s staff, regardless of how stupid the orders er, um requests are, we put the orders in to save time and to save administrative hassles.

Harry was the unfortunate soul who was drafted one Sunday morning. It seemed that the nursing home staff felt it was odd that Harry hadn’t had a bowel movement in two days. He probably had an obstruction. Needs an acute abdominal series and some labs.
I called BS. Harry had normal bowel sounds, no palpable masses, and no impaction on his rectal exam (sorry about having to do that on an early Sunday morning, Harry). Besides, it’s entirely normal for someone not to have a bowel movement for two days. We called the nursing home and told them Harry was coming back.
Nope. Need labs and an abdominal series.
Bastards.
Needless to say, the labs and the abdominal series were [gasp] normal.
So I asked Harry “Would you like me to give you something to help you move your bowels?”
Harry replied “Sure, doc. Always nice to have a good BM every day.”

We called the ambulance and made arrangements for transfer back to the nursing home … after being forced to fax them the lab and x-ray results.

So I’m curious. Would it have been mean for us to give Harry lactulose and Milk of Magnesia as the paramedics were loading him onto the stretcher to take him back to the nursing home?

4 comments

  1. It would have back-fired (ahem). They’d have sent him back for diarrhea.

  2. And we complain about the high cost of health care in the US.

  3. As a gero shrink, sending demented NH pts to the ED for agitation is not only ridiculous, but harmful to the pts. Does the NH really think loading these pts up into a loud, fast ambulance with strangers, then unloading them into a loud, hectic ED with more strangers is really going to lessen their agitation? By the time these pts get to the ED, one really has to wonder what agitation is being treated – the one the NH saw, or the one that was created by their actions. Demented NH pts should be treated/eval’d in their NHs for every issue, when at all possible.

    What about obtaining collateral info from family (via phone “No BM for 2d is usually perfectly normal, but to be sure, since the NH thought it an emergency, I needed to wake you up to see if you knew what his usual bowel habits are”) for every pt that NH sends and while discussing the situation with them, making it obvious (without actually saying so, in order to avoid the dreaded dept chair call) that sending poor grandpa to the ED for something that should have been tx’d/eval’d in the NH is only going to agitate him/put him at risk for nosocomial infection/keep him awake and waiting for hours when all this could have been done in the comfort of his own room? I would be shocked – shocked, I say – that the NH did not contact the family member prior to transfer for this nonemergent issue and suggest that they take the issue up with the NH admin in the morning.

  4. I work in a nursing home after many years in ED nursing. My facility rarely sends out residents to the ED if it is something we can handle. So, usually when a resident goes to the ED from my home, they are almost always admitted. Let’s face it many nursing homes aren’t capable of taking care of their residents appropriately. I have learned so much working long term care. I love it and my experience is taken seriously.

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