April 14th, 2007 by Dr. Val Jones in True Stories
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Several years ago I was taking care of a pleasant elderly woman with a heart condition on an inpatient unit. One morning I went into her room to check on her and I found her sitting up in bed, clutching her purse and crying.
“What’s wrong, Mrs. Johnson?” I asked, perplexed.
She blew her nose in a Kleenex and replied, “Someone stole my insurance cards, my money, and my credit cards! They were in my wallet just yesterday evening – and this morning they’re gone.”
I paused for a moment, considering the order of priority in which she reported the missing items, glanced at her telemetry monitor (her rhythm was regular though her heart rate was elevated from crying), and asked if she knew how this might have happened.
She told me that she suspected that a certain patient had sneaked into her room in the middle of the night and removed the items from her wallet.
“How do you know it was that patient?” I asked, growing suspicious.
“I’ve seen her sneaking around at night in other people’s rooms – a couple of nights ago she was in here digging through my roommate’s dresser drawers.”
The suspect was a 38 year old woman with a known history of heroine abuse, who was admitted to the General Surgery service (conveniently boarded on our Internal Medicine floor) from the Emergency Department to complete an acute abdominal pain work up. This woman had already terrorized the surgical intern assigned to her case (as I had heard on rounds the day before) by chasing her around the hospital room with a hypodermic needle. Security had come to restore order and had found a stash of heroine and some needles in her bathroom that had been brought in by her visitors the night before. The team decided not to discharge her because they had discovered a large abscess on her ovary (from an advanced and untreated sexually transmitted disease) that they felt obligated to drain and treat her with antibiotics. Of course, on the morning of her scheduled surgery she ate breakfast, making it unsafe to put her under general anesthesia. These games continued (sneaking food before surgery, refusing surgery or medications, then changing her mind, then claiming to be homeless with no safe discharge plan, etc.) so that her length of stay grew from days to weeks.
“And now,” I thought to myself, “she’s using our hospital as a flop house, victimizing MY patients on the same floor – stealing their belongings in the middle of the night?!” This was the last straw. I told Mrs. Johnson that I would get to the bottom of the matter.
And so I waited for the victimizer to leave her hospital room for a scheduled test – I sneaked into her room and went through her bedside table drawers. Lo and behold, my patient’s ID and credit cards were stashed in a box with a bunch of other IDs that clearly didn’t belong to the woman.
I called hospital security, and we reviewed all the items that she had stolen. As it turned out, she was admitted to the hospital under a stolen Medicare card (the woman had claimed to be on disability). Her name matched with our records of a 67 year old woman, so we knew that she had been admitted under another’s name – and the admitting clerk had not noticed the age discrepancy. A careful record search turned up the drug user’s previous admissions under this alias. This predator had been gaming the system for years, eluding detection!
I asked the security guards to help me interview other patients on the inpatient unit to see if they had experienced anything out of the ordinary over the past few weeks. What we found was astounding. Several frail elderly patients described similar night terrors (being unable to stop the woman from going through their personal items at night) and one gentleman with advanced AIDS, who was admitted for treatment of severe pneumonia, reported that the woman had attempted to molest him in the middle of the night when she was high and in a hypersexual state.
Thanks to our investigation, many patients had their belongings returned to them (though some of their jewelry was not recovered – the woman probably sold it for heroine to her visiting dealer), and I heard that the predator was caught by the city police after choosing to leave the hospital against medical advice.
I don’t know what happened to this woman after that, and I doubt that the police were able to detain her for very long. I felt horrible for the patients who had been victimized in their ill and vulnerable states, and I wondered what kind of lasting psychological damage that this woman had inflicted upon them, especially poor Mrs. Johnson. I also felt frustrated and vulnerable – unable to really protect my hospital from future assaults. What could I do, stand in the Emergency Department each night to identify her if she chose to return? I can only imagine that this woman is still up to her old tricks at a neighboring inner city hospital near you…
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 12th, 2007 by Dr. Val Jones in True Stories
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I worked in a hospital that was so old that the bathroom doors in the patient rooms were not wide enough to accommodate a walker or certain kinds of wheelchairs. The hospital had resisted any upgrades, because the building codes stipulated that if any improvement was made, all of the necessary upgrades were required. The cost to fully comply with the new codes was enormous, and so in some twist of bureaucratic irony – nothing changed for decades upon decades.
One morning I entered one of my patient’s rooms to check on her. There she was, 4’11”, 85 years old, with a white bob and a thin frame, wearing nothing but a hospital gown tied only at the neck. She smiled brightly as she caught my eye. She was clutching her walker, attempting to exit her bathroom straight on. I watched her as she slowly inched towards the narrow door, bumped into it and then backed up to try again. She made several valiant efforts to get out of the bathroom, holding onto her walker for stability. (Though none of the attempts involved turning the walker sideways to fit through the door.) Trapped and befuddled she smiled at me good naturedly and concluded, “I think this hospital gown is too heavy.”
When I remember this patient, I imagine how so many people are trapped in the healthcare system that is old and poorly designed. They want to get through barriers to care, have inadequate resources, and a limited understanding of what’s actually blocking them from the help they need. If you feel that “your gown is too heavy,” I hope that Revolution Health can make things better for you… we want to empower you to understand the problem and get the help you need. Let us know how we can help!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 2nd, 2007 by Dr. Val Jones in True Stories
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Continuing on with the car accident theme… A patient came to see me in the clinic. She had been run down by a bike messenger (could it have been my friend with the bleeding leg?) when attempting to step out of a bus onto a cement curb. She had a lot of pain in her shoulder and side, and was taken to the ER where a chest XRay was unremarkable. She was released with a prescription for extra strength Tylenol.
Still in pain, she made an appointment at the hospital’s orthopedic clinic for the next available time slot (she was covered by Medicaid) where she met with a young resident who suspected that she was a drug seeker and sent her away with “reassurance” and more Tylenol.
The woman, knowing that if she came back to the clinic again, she’d probably see a different physician (and could therefore get a second opinion) – made another appointment. The next orthopedic resident read her chart (where the previous resident had written that the patient exhibited drug seeking behavior) and barely listened to the woman’s story. But after the patient insisted he do something, the orthopedist did what most do with “chronic pain patients” – send them to the rehab doc.
And so, nearly 6 weeks after the accident, I met the woman in the rehab clinic. I had read the ortho notes prior to seeing the patients and was nearly convinced from their descriptions that she was a belligerent, drug-seeking nightmare.
The woman was thin and irritable. I asked her why she had come to see me, and she said she thought I was going to do some physical therapy with her. I asked if she could recount the events in her own words, and explain what exactly was troubling her. As the story unfolded, I was saddened by what she described – the endless frustration of being in pain, of being bounced around from one young physician to another in clinics overflowing with patients, and of being labeled as a drug seeker. And all this after a very painful encounter with a hit-and-run bike messenger.
I asked her to describe her pain and point to it exactly. She said it had been slowly improving, but that it hurt most when she breathed in and there was some point tenderness over her 8th, 9th, and 10th ribs. I asked her if she had had a rib series… nope just a chest XRay.
I told the woman I thought it was likely that she had fractured her ribs, and that rib fractures are often hard to see on XRays, especially chest XRays. I also told her that there wasn’t any real treatment for rib fractures, except pain management and time to heal. Her face lit up.
“So you believe me? I’m not crazy?”
“Sure I believe you,” I said. “I’ve fractured ribs in the past and I know how painful it is. When it happened to me no one believed me either. My chest XRay was normal.”
“So what did you do about it,” the patient asked, looking at me compassionately.
“The truth is, I had to sleep sitting up for a week or so, and I breathed very shallowly for a while. Eventually, though, the pain went away on its own.”
“Thank you for listening to me, doc,” she said, tears welling up in her eyes. “Even though there’s nothing I can do about the ribs, I’m glad to know what the pain is from, and that I’m not crazy.”
I wrote a short note in the chart, documenting my impressions. I did not recommend physical therapy for the patient, but to follow up if needed.
Apparently, the woman had one more clinic appointment with the orthopedic team. They read my note and ordered a rib series to confirm the diagnosis. The rib series showed healing fractures of ribs 8, 9, and 10.
I never saw the patient again, but I’m quite sure that explaining her diagnosis was the most therapeutic thing that we did for her.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 1st, 2007 by Dr. Val Jones in True Stories
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A few years ago I was walking home from the hospital after a long shift, when I witnessed a bicycle messenger struck by a taxi cab. The cyclist was riding at high speed across a crowded intersection and the cabbie was accelerating through a stale yellow light. THUD. The man flew across the pavement, the cabbie screeched to a halt, horns honked, a crowd gathered… I ran up to the man to check him out. His right shin was bleeding (he was wearing shorts), but I didn’t see any obvious deformities or broken bones.
The man was panting, his adrenaline pumping. I asked him to stay down for a moment while I checked him out. “F-off,” he snarled, “I don’t need your help.” Since I saw him fall, I knew that he hadn’t sustained a head injury that could explain his potential disorientation and poor decision making. I called 911 on my cell phone and gave them the scene coordinates while I tried to get the man to agree to get checked out. “I don’t need a f-ing ambulance, don’t call them!” he screamed, blood dripping down his leg. I did my best to reassure him, but he was adamant. He got up and started limping towards his bike (which, quite miraculously, was not bent out of shape from the blow). I continued to plead with him to just wait a moment to let the paramedics take a look at him, but he would not be detained. Short of using brute force to keep him down, there was nothing I could do. Distant sirens sounded, he hopped on his bike, muttered “I don’t have insurance” under his breath, and rode off. The taxi driver appeared extremely relieved. The crowd dispersed, the taxi left the scene.
When the fire truck arrived, I explained the situation. They asked which direction he’d driven off in, and they pursued. I don’t know if they ever found him, but catching a cyclist with a fire truck on the crowded streets of Manhattan is unlikely.
——–
A few weeks ago I was walking down a narrow street in DC. An ambulance was parked in the middle of the street, a small SUV was in front of it, and a middle aged woman in a dark suit was sitting on the asphalt appearing angry but unharmed. I heard from an onlooker that she had darted out behind the SUV while it was moving slowly in reverse. She had been struck lightly, but was speaking loudly about suing the driver, and was demanding that she be taken to the ER for a full check up. The EMS team interviewing her was hesitant to put her on a stretcher since it was so obvious that she could walk. The woman was refusing to get up, and they were trying to figure out how best to carry her.
I gritted my teeth and walked away, wondering what kind of legal torture the SUV driver was in for.
These two car accidents left an impression on me – the uninsured will go to extremes to avoid costly medical care, while the personal injury lawyers rack up serious cash on trumped up claims. What’s the point of this post? I guess it’s a reminder to look both ways before you cross the street, drive carefully to avoid pedestrians, and make health insurance a priority!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 1st, 2007 by Dr. Val Jones in Medblogger Shout Outs
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In a really engaging recent post, ER doc Edwin Leap (via GruntDoc) discusses why it seems that the general public is outraged at reports of the occasional specialist who makes $500,000 and yet do not flinch at the much larger salaries of football players, musicians, or media tycoons.
I posted a response to Dr. Leap’s blog post, explaining my take on why people are so angry. Let me know if you agree:
You are right that there is a lot of anger towards physicians – it is the collateral damage of the broken physician-patient relationship. When third parties (insurers) got between us, and reimbursement dwindled with drastic cuts in Medicare/Medicaid, physicians had to make up the difference in volume. When you see 30+ patients/day none of them feels as if they’ve had a valuable interaction with you. And the physician’s memory of each individual patient (and their psycho-social context) becomes dim.
When we lose the sacred, personal, physician patient relationship – we lose the best of what compassionate individualized medical care has to offer. This is why patients believe that a government sponsored system can give them the same level of care that they currently receive. I shudder at the idea of handing over medical decision making to a distant bureaucracy that only knows what’s right for a population, not for the individual. But if doctors continue to treat patients like a commodity, the patients are actually receiving nothing more than population-based care anyway. Quality care is personal, and the physician-patient relationship is a trusted bond that cannot be easily broken. We need to know our patients well so that we help them to make the best possible decisions for their personal situation. I believe that the IMP movement (see Gordon Moore’s work) – where PCPs use IT to drastically reduce overhead costs so they can afford to see fewer patients – is one of the best ways to improve healthcare quality.
As far as Emergency Medicine is concerned – we need to get the non-sick patients out of the ER and back to the PCPs. Easier said than done – but if the patients have a real relationship with their PCPs they’re less likely to substitute an ER doc inappropriately.
My 2 cents! 🙂
Patients are angry about physician salaries because they know instinctively that they are not getting the quality care that they are paying so much for… Moreover, the major cost causers (hospitals that cost shift unpaid bills to the uninsured and take large cuts for hospital administrator salaries, and for-profit insurance companies) don’t have a name and a face to the patient. So docs take a double dose of anger on the nose, further damaging the already strained relationship. We must go back to our roots – and support the personal doctor patient relationship that has been a pillar of American medicine. Revolution Health can be our meeting place… the new digital medical home, supporting the old physician-patient team decision-making approach!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
