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A Little Old Lady’s Power In The ER

Here’s my column in the August edition of Emergency Medicine News. A person who seems powerless may hold an entire emergency room hostage!

Magic Words: ‘I Have Chest Pain’

Propped in her bed, frail and weak, the little grandma sighed. Her complaints were legion: weakness, poor appetite, poor sleep, joint pain, cough, dry mouth. Her daughter, eyes rolling, was trying to balance three reasonable emotions. She desperately wanted to go home and rest after spending the day in the ER. She truly wanted to avoid her mother’s admission to the hospital, and she was, graciously, sympathetic to the physician who brought the bad news.

‘Mrs. Adkins, I know you feel poorly, and I’m sorry. But I have to say, I can’t find any reason to admit you to the hospital. You’re right as rain. Isn’t that great?’

‘You mean, I’ve been here all this time, and had a gallon of blood drawn, and all them x-rays and a CAT scan, and there ain’t nothing wrong? I can’t believe that. I feel terrible.’ When she said the word terrible, she smacked her lips and looked away. She propped her hands on her lap and intertwined them; and she managed a subtle, but expressive, sniffle.

‘Ma’am, I truly understand,’ said the doctor with one hopeful hand on the door. His family, also, waited for him to come home. The shift was at its end. There was a grill, and burgers, and the children were splashing in the pool. ‘Maybe you just have a little virus…these things happen.’

‘Virus? I don’t have no virus. I feel like I’m dying.’

‘Mama,’ her daughter interjected, ‘let’s go home and see if you feel better after a good night’s sleep. Maybe the doctor can give you something to help you sleep. Can you doctor, can you?’ She looked at him, pleading, as visions of sleeping pills danced in her head.

‘Yes! Yes I can! We can help your mom to sleep, absolutely. I’ll write you a little prescription for…’

‘I have all the pills I need or want. Pills don’t do nothing. I don’t want to sleep, I want to feel better.’

(Her daughter and the doctor thought, simultaneously, ‘you haven’t felt good since 1976, nor wanted to since 1950.’)

Her daughter put head in hand and shook it, slowly, side-to-side. The drama played out once every month or so. Her mother had tried nursing homes, but stating ‘nobody does anything for me there,’ she had abused the staff and signed herself out. Now, in her small trailer in her daughter’s back yard, she spent her declining years in endless, robust, purposeful decline. Misery was her art-form; complaint her sonnet. And therefore, she held her daughter and son-in-law hostage to her whims, her age and her agony.

But this day, she focused on the man in the blue scrubs. He said, ‘I know many things are bothering you, but Mrs. Adkins, right now, what is the one thing troubling you most? Can you limit it to one complaint? One problem?’

‘Sure I can, young man. Ever since I’ve been here, you know, nobody has even bothered to ask, but I’ve been having…ch…’

‘Chills?’ he asked. Her daughter looked up; she knew what was coming. It was the game-maker, the deal-breaker. It was the trump card.

‘No, you moron, I have chest pain.’ The words jumped from her dry lips with remarkable clarity. The words echoed off the walls and hung in the air. The young doctor saw his burgers burning, his children in towels by the pool, his wife looking at her watch. The woman’s daughter was almost relieved. She was out of the equation now. She looked at the doctor with a mixture of pity and admiration; but also with the relief the living feel before the dying. Survivor-guilt, that’s what it was. Tonight, she would have a reprieve; she would be ransomed for a day, maybe two.

The sweet lady looked up with a twisted smile. ‘Yes, that’s it. I have chest pain. It’s pretty bad. You know, I used to smoke. Today I was short of breath. Last night, my left arm hurt and I broke out in a terrible sweat. One doctor told me I had a silent heart attack.’

Her daughter reached out, one last time, ‘your air conditioner was broken, mama, that’s why you were sweating.’ Her mother was animated, and sat bolt-upright. ‘You don’t know what you’re talking about. You want me dead. My daughter wants me dead, she always has.’

At which, the daughter stood, tearful, and walked to the door. She put her hand on the young doctor’s shoulder and said in a whisper, ‘good luck with that. I’m gone. I’m sorry, but I have to leave or else I’ll….who knows. You’re a fine man; you’ll have a crown in heaven.’

Shifting his weight, her doctor took a deep, cleansing breath, closed his eyes, and advanced on his aged captor, stethoscope in hand. He re-focused his attention, then left and ordered more of this, more of that. He knew where it would all end.

‘Might as well order a telemetry bed for Mrs. Adkins. She isn’t going anywhere today.’

‘Chest pain?’ asked her nurse. ‘She’ll be down here all night; the unit and step-down are all full. Daggone it, we’ll be fluffing her pillow and answering her call-light for 18 hours. You’re weak.’

‘No, she’s just too powerful.’

And the young doctor did what any compassionate, caring professional would do; he called her family doctor, who was on the way out of the parking lot, headed for a movie with his young wife. The name ‘Mrs. Adkins’ almost made him crash into the gate. He put his head on the stearing column for a few seconds, then turned around and parked, braced himself, and walked into the ER, into her room, and into his own period of servitude.

‘Where have you been? Nobody has done anything for me here today!’

‘Yes ma’am,’ he said.

He was one more hostage among many; victims of the whims of an old lady with endless, almost cosmic power to direct those around her.

She smiled inside her seemingly frail body, knowing it would be the best night ever.

*This blog post was originally published at*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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