PartTwo: How Not to Act for Emergency Room Physicians

I didn't figure that I would have to write a Part 2 but as it turns out, I did have to after all. The only "redeeming" aspect of having to re-visit the subject is that the physician who inspired this piece of writing is not the same physician who inspired Part 1.

1.  Glance at the paperwork which declares patient to be receiving hospice services. Grumble.

2. Order and have completed four tests which involve a C-T scan, an x-ray, bloods, and urinalysis to be completed before family arrives.

3. Ask family if Old Man "has cancer." Tune out short explanation given by knowledgeable family member about the benefits of hospice for Old Man, even though you asked about the benefits. In fact, you admit to not knowing that hospice has a hospice in the same small town that the hospital is located in but hey, that does not matter. Tell family that Old Man "is not dying."

4. Admit to not knowing what Lewy Body Dementia is but tune out the short explanation given by knowledgeable family member [who admittedly is sick and tired of explaining the differences between L.B.D. and Alzheimer's to medical personnel].

5. Push for Old Man to be admitted to hospital as a non-hospice patient in order to aggressively treat something which has a low chance of being bacterial even though the full results from the lab will not be known for at least twenty-four hours.

6. After making your pitch, ask family if they will support this.

7. When family informs you that they are calling the hospice team first before supporting anything, present them with the telephone by slamming it on the top of the desk. [Family in fact did not need to use the hospital phone. Family comes equipped with freshly charged cell phones].

8. After family informs you that hospice is coming to the emergency room, try again to talk family into hospitalization and aggressive treatment. Tell family that if not, you will send home a script for a broad-spectrum antibiotic. [See #14].

9. Stomp around a bit. Come back into the room where patient is sleeping and say, "Hospice is not here yet. Are they coming?" Family responds in the affirmative. Leave the examination room. Mill about the nursing station.

10. Act annoyed when hospice in fact calls the emergency room and directly asks to speak to you. Tell hospice over the telephone that you-- an emergency room physician who have never even met Old Man before this emergency room visit-- think that Old Man should not be receiving hospice services.

11. When hospice shows up, tell hospice and family that the first and best option is to admit patient to hospital in order to aggressively treat the possible bacterial infection for which patient is non-symptomatic at this time. 

12. Demand to know if case manager is also a nurse. [The answer is yes].

13. Advise that the hospice case manager will have to call the lab to get the results so patient can be admitted to the hospital [in a day or two] in order to aggressively treat the supposed possible bacterial infection. Don't ask what the patient [who still has opinions about his health care in spite of his current health status] or the family may want to do about this situation.

14. Insist that the best option is to allow patient to be hospitalized right then and there. Allow as to the second option is discharge without any script for an antibiotic. [This results in the case manager having to contact Old Man's doctor for said script].

15. Waltz away with your huge false ego and awful bedside manner intact. During the whole time, do not say two words to Old Man. [Family and hospice know better than you do about patient dignity and therefore strive to include Old Man in the conversation whenever he is awake].

sapphoq on life says: Fortunately, not all physicians are like the two physicians that Old Man and family have encountered in the particular emergency room.
     Unfortunately, hospital does not have a written protocol for medical staff to follow when dealing with patients on hospice who arrive in emergency room. This leads to situations where the treatment encountered by a dying hospice patient will be extremely variable, depending upon the personal beliefs, philosophies, and attitudes of whatever emergency room physician happens to be on duty at the time. 
     All physicians ought to honor the choice that terminal patients have made to utilize hospice. Hospice allows patients to avoid over-treatment and aggressive treatments according to their wishes. I will be advocating for systems change in respect to hospitals in the state where Old Man lives and procedures for care of all hospice patients who have to utilize emergency room services for an acute medical emergency.
     

How NOT TO Act: for Emergency Room Physicians

1.  On old man's first emergency room visit of the weekend-- on Friday morning-- give him a mild over-the-counter non-aspirin "pain reliever" for excruciating lower left quadrant back pain after running a ton of blood work [all negative].

2.  Only prescribe an effective agent for pain relief after old man's adult child appears in the emergency room and insists on something stronger.

3.  Diagnosis: back spasm. Illustrate this by grabbing that part of the back suddenly. Ignore the discomfort of the old man while doing so.

4.  On old man's second emergency room visit of the weekend-- on Saturday morning-- insist that the prescription given yesterday will work.

5.  Order a C-T Scan "just in case". [negative]. Oxygen level: 88. Ignore the implications of that and give oxygen until the old man leaves the emergency room.

6.  Advise the adult child to "pretend to be stupid" and lie to the trusted family doctor in order to get him to order physical therapy with ultrasound treatments for the misbehaving muscle.

7.  Diagnosis: back spasm "but really more of a back pain." Ignore the protests of the adult child and the nurses who think there is something more going on.

8.  On old man's third emergency room visit of the weekend-- on Sunday night after he was found on the floor [because he fell]-- insist that his back AND neck pain is from the misbehaving back muscle, left lower quadrant.

9.  Send him home. Nothing much wrong here. Diagnosis: back spasm/ back pain.

Note to idiotic physician: Had you LISTENED TO HIS CHEST with a steth, you might have discovered the pneumonia which the family doctor was able to diagnose on Tuesday without grabbing the old man's back and causing him more pain.

The pneumonia was spreading to the other lung by Tuesday and required two antibiotics to treat.

Grade: FAIL. 

Doctor, Doctor

Appointment is at 1:15.
I arrive at 12:35.  The office is 20 minutes away.

Dad: (coming out of dining room):  I have to wash my hands.
Me:  Okay, Dad.  I'll wait down here for you.

Dementia has its' own timetable.  Dad no longer understands why he should have to show up anywhere at any given time.  Fortunately, the doctor and the doctor's office help all understand this.  Various housemates of Dad float by and we greet each other.



Dad:  (at 12:58).  I'm ready.  You go out first and start the car.  (translation: I don't need your help walking down the stairs today).

I start the car.  I watch Dad walk down the stairs.  I help Dad into the car, straighten out the seatbelt.  Dad has one brown glove and one black glove with him.

Dad:  (at 1:05)  Why are we going to the doctor?  Which one?
Me:  You were complaining about shooting pains in your leg near your scab.  And burning.
Dad:  Okay.  (looks around vaguely).
(translation: I have no idea what you just said but I'll ride along and see where we end up).



In doctor's office at 1:25.  The staff see him arrive and check him in as I am parking the car.


Doc:  Your scab is healing.  Everything is okay.  The cellulitis did not come back.
Dad:  Doc, is my leg going to fall off ?
Doc:  Your leg is firmly attached.  You are going to be alright.
Dad:  But my ankles are different colors, see?
Doc:  (inspects ankles, straightens out one of Dad's socks for him)  Your ankles are that way because of your age.


Me: (out in the hallway with the doctor)  Sorry Doc.  He said he was having shooting pains and burning.
Doc:  I'd rather have you bring him in and it be nothing than you miss something that he does need medical attention for.


Dad and I go out for coffee at the favorite local diner.  This is something that we enjoy doing together.  Dad orders coffee.  I order hot chocolate.  We split an English muffin.  Dad comes back from the mens' room and is able to tell the manager that the sink water in there was too hot.


We start the drive back to Dad's home.
Dad:  My leg didn't hurt in the doctor's office.  Now it is burning and has shooting pains.


sapphoq on life: And I even had a question about which side of the family donated a genetic propensity toward anxiety to me???

Dementia is hell.  Dementia is painful.  Dementia tears families apart.  Dementia has torn our family apart.  I am losing one person.  Dad is losing everyone.  Dad was always there for me and now it is my turn to be there for him.  I feel very fortunate and honored that I can be a comfort to Dad in the evening of his life.