- COPD
- CHF
- Hx of Pneumonia
- 93 years old. That right there is a definition of a difficult clinic patient.
- Shortness of breath and weight gain and fever
- 96% oxygen saturation on RA
- A subjective SOB with ambulation.
- Hx of CHF
- Hx of COPD
- Hx of AFib
- Hx of Stroke and aspiration pneumonia
- Hx of lots of stuff
The fact that I'm talking about this gives you the answer. I was called directly to admit the patient. I can see her point. The patient is old with lots of medical conditions. But the thing that strikes me as odd is the 96% on RA. That's normal folks. That's what my oxygen saturation is. Normal. So I find myself wondering what the urgency is to spend $8,000-$10,000 of tax payer money bringing somebody in for SOB.
I can understand her point. The fever. The weight gain. The multiple medical conditions. The age. It's all working against both the patient and the doctor. The safest thing to do is admit the patient to the hospital, if not for anything else than to observe. So I accepted the patient. I was told that the patient would be driven directly down to the hospital from the clinic.
One hour passed...
Two hours passed...
Three hours passed...
After three hours, I decided to investigate. Did the patient code in the clinic? No. Did the patient come in as a trauma from her car accident on the way over? No. Did the patient go to the wrong hospital? No.
The patient went home for a "Potty Break and A Power Nap". Those were the exact words from the comprehensive care doctors office.
Now America. You tell me. Should this patient be in the hospital?
The issue here is that the referring physician either cannot cope personally and professionally with diagnostic uncertainty or doesn't have the communication skills to get the patient and/or family to accept some initial diagnostic uncertainty and agree to initial empiric treatment. Many physicians do not have these skills or are too stressed to use them. It's a shame, because the ability to keep patients out of the hospital depends upon the ability of the office physician to cope with diagnostic uncertainty and communicate this concept successfully with patients.
ReplyDeleteAnon 653 has a point there. The 93 yr old is probably only too aware she will not get much rest in the hospital. And chronic pts know this too. One has to be "well" in order to seek out adequate medical treatment these days too. Send a home health care nurse, with any needed medical equipment aids, out to monitor. Pt would be much more comfy at home. No increase in coughing, change in sputum? May not be a copd flare, at least yet.
ReplyDeleteSend her home with a VNA referral. Home is better for these older folks anyway. She'll just contract something else at the hospital anyway and get skin breakdown. Hopefully at the age of 93 she has a DNR order and can comfortably recuperate in her own environment.
ReplyDeletehow much time do you think the primary doc needs to adequately assess this patient? one hour? hour and a half? keep in mind no labs or radiology immediately available.
ReplyDeletehow much should they be reimbursed for this?
should we allow gainsharing-if they keep the patient out of the hospital, the primary doc gets a fraction of the money they saved the hospital? at least for heart failure, these medicare experiments to provide extra resources and try to decrease admissions have not been very promising so far.
This sounds like there might be a market for house calls. What about sending this person home and following up with a house call every couple of days? What does Medicare pay for this?
ReplyDeletegood enough to go home and take a potty break and a power nap before direct admission should mean good enough to go back home.
ReplyDeleteMaybe her family had the good sense not to let her get in your tender clutches for a bunch of tests when she was feeling a little better. Yes--docs send even young people to the ED! Lots! Call them late in the day? ED. Weekends? ED. Just get rid of us.
ReplyDeleteseriously, I'm going to do everything in my power to stay out of the ER, not get a C-collar, not get a chest tube, not be made NPO, blah blah blah.
ReplyDeleteI'm in the middle of a trauma surgery rotation - and enjoying it - and there's no way I'd want to be a patient unless absolutely absolutely necessary. I think if more people knew what they were in for before their hospital stay, they wouldn't come in the first place. I believe my patients when they say they've had an exhausting day.