Intact Humor Reflex Is A Good Sign For Discharge.

Humor is often a good sign the patient can be discharged to home. 

So I get asked to consult on a patient in the emergency room to admit for acute exacerbation of multiple chronic medical issues. Reading the nursing home transfer sheet clued me into exactly what the specifics were around the transfer.

92 year old female transferred for "confusion", "UTI", "3+leg swelling", "Neck and back pain" and "nausea and emesis".

That sounds like a sick lady. Especially at 92 years old. Something the FREE=MORE American medicine can certainly provide for. Fortunately for me, hospitalist medicine is continuity of care for a very large sub population of the chronically ill who present with an acute exacerbation of multiplemedicalproblemitis

And this is a golden example of how hospitalist medicine brings value, not only to hospitals, but also to the Medicare National Bank. This sweet old lady just happened to be a bounce back of mine.

Perfect I thought, old lady, nursing home, multiple medical problems, sounds like the expected course of action. She'll need admitting for sure. Except she didn't. Because I knew her.

I knew

• The back pain was chronic
• The nausea and occasional emesis has been worked up since the Carter years, and has experienced the magic of American medicine first hand trying every test known to man.
  
• The edema was non existent. Fat legs do not equal edema. Especially when the rest of the body habitus confirms the diagnosis of adipose extremis.
• The UTI as well was a sham. I never believe urinalysis from anywhere, ever, unless it is collected by sterile cath technique. Urine from the ED? Crystal clear

Not to mention the chronic hypercapnic respiratory failure with a baseline CO2 of 70, a baseline creatitine of 1.8 and a pacemaker waiting to discharge its last electron from a sweetheart as big as gold.

The only thing left to address was her confusion.

Me: Why are you here in the ED today?
Her: I don't know, the nursing home sent me.
Me: I'm not sure I could do much for you in the hospital. Everything here in the ED appears to me like you have a 92 year old body.
Her: You're going to be 92 some day as well.

Final diagnosis: multiplemedicalproblemitis without exacerbation with intact humor reflex. ICD code 867.53.09 (go here where I explain ICD and CPT codes). Disposition. Home. Intact humor reflex is always the best sign of intact cognition.

I saved the Medicare National Bank. an $8000 admission, of which Happy gets a piece of stale bread as a thank you. Imagine for just one moment had any other species of MD been called to admit.

Now go work out and stop eating McDonald's. I may be able to prevent the Medicare Ponzi scheme from collapsing on itself for a millisecond or two, but in the grand scheme of things, you had better find a way to avoid disease at all costs. Because the money will be long gone admitting 92 year olds without acute exacerbations of multiplemedicalproblemitis.

And trust me. I could admit her and create Medicare medical necessity out of any one of her multiple medical conditions, jut by knowing what to right and where, even if it is all factually accurate.  There is no incentive for me to send her home, and I do it anyways. I take all the risk of her getting worse out of the hospital. I get no benefit of billing her on multiple hospital days. Economically speaking, good medical decisions do not pay.

The system is just not set up to reward good medicine. It rewards volume. I may have saved the hospital a money losing internal medicine admission and Medicare thousands in DRG payments and opened the bed up for a more lucrative surgical or procedural based bed fill. So I guess, in one way, I have brought value to everyone involved. Including the patient, who didn't want to be admitted.

Try measuring that for a quality indicator.

If you're a student or a resident, it's time to tuck away  these other great medical signs:

• Handsome Sign
• Sleeping Husband sign
• O and Q sign
• Twenty sign
• MFer sign
• Texting in the ER sign
• Band-Aid sign
• How to find a lost cell phone in the hospital:  Happy's honesty sign
  
• Fibromyallergia sign
• Denture Stains sign
• Square Root sign
• And while you're at it, check out these funny homeless signs.