Several times in the past few days we have gotten ambulance runs from the nursing homes in the middle of the night to evaluate elderly nursing home patients for “unresponsiveness”. When the “unresponsive” patients arrive, they are at their baseline mental status and, after the obligatory workup to rule out the bad causes of “unresponsiveness,” nothing is wrong with them.
Is “unresponsive state – rule out REM sleep” a legitimate discharge diagnosis?
Then, last night we got an 82 year old COPD patient by ambulance from a nursing home who was having “severe shortness of breath” and “hypoxia”. Her oxygen saturation was in the 70s in the nursing home (normal is in the 90s) and she was “dusky,” prompting the ambulance call.
When she arrived by ambulance, with her usual oxygen settings on the nasal cannula, her saturation was a respectable 92% – an acceptable value for a COPD patient. Was her shortness of breath and hypoxia due to some acute underlying medical disaster?
Fortunately, I like to talk to the EMTs when they bring in the patients. In this case, the patient’s nurse told them that the patient took off her oxygen to go outside and smoke a cigarette in the cold. She enjoyed the first cigarette so much that she had a second – while her oxygen canister waited longingly for her inside the nursing home. She may have gone for a third and turned into a smokesicle, but her nurse noted the lonely oxygen canister in the hall and investigated, finding the patient standing out in the cold.
Now of course none of this was written in the transfer papers and we had to call the nursing home to verify the story. The patient’s nurse had left for the evening and the nurse that was there had no idea about the patient, so we had to call the previous nurse on her cell phone at 11:30 at night. She didn’t answer her cell, so we had to call her house. Oh, and don’t forget the obligatory emergency department testing just so that we can prove that the patient really is at her baseline before sending her back – just in case she wakes up dead the next morning.
All this because granny wanted a couple drags from a Marlboro.
Kind of ridiculous, huh?
Although I get frustrated by what some people perceive as “bullshit nursing home transfers,” I also find myself bowing to the same pressures that nursing homes have when I see the patients in the emergency department.
How often does any emergency physician look at a frail elderly nursing home patient who complained of shortness of breath and not order any testing? I’ve done minimal workups on some patients (including Granny Marlboro above) and have had people tell me that I am lugging a couple of coconuts around in my scrub bottoms for not doing a million dollar workup on all the nursing home patients … and even for sending the patients back to the nursing home when they come in with vague complaints.
If a patient complains of shortness of breath in the nursing home and the nurses don’t send the patient for evaluation, the nurse and the nursing home will be investigated by all the clipboard brigades and would likely be sued if the patient suffered a bad outcome.
Similarly, if I don’t do a thorough emergency department workup on a nursing home patient with a vague complaint of shortness of breath or weakness or fleeting chest pain and the patient has a bad outcome after their emergency department visit, all the people who wouldn’t have the gonads to make a prospective decision about what care to provide to the patient would have no problem retrospectively questioning whether my care was adequate and appropriate. They might even make up retrospective assertions about why much of the negative testing I performed was “unnecessary”.
What’s the bottom line in megaworkups for minor complaints? Fear of liability. Some of us have less fear than others, but that fear still drives a whole lot of medical spending.
Just another reason health care reform will not never go anywhere without liability reform.