Tuesday, January 27, 2015

Dr. Orthochick: Dispo

On Wednesday when I was operating with Dr. Anal he admitted our last hand job patient of the day. She was an 88 year old lady who had fallen and fractured her patella as well as her distal radius, the patella was being treated non-operatively and she was allowed to weightbear as tolerated as long as she was in her brace, but the radius needed surgery. Dr. Anal had spoken to her for a while and decided she would benefit from being in the hospital overnight so that she could get placement in a nursing home and so she could get a formal consult for her depression. Normally distal radius is an outpatient surgery.

In theory, Dr. Anal is a great guy for understanding that the patient really did need to be in a nursing home right now because she couldn't take care of herself and that she was suffering from depression.

The reality is a little different.

So the patient was admitted around 11:00AM on Wednesday. The hospitalist saw her later on that day and started her on Zoloft before calling a psych consult. By 11:00AM Thursday, discharge planning still hadn't seen the patient. Psych then saw her and decided she wasn't suffering from depression and stopped the Zoloft. They then called a geriatric assessment, who determined that she was at a high risk for falls and should be in a nursing home temporarily. They also ordered physical and occupational therapy. Social work saw the patient at 16:00 and asked her about nursing homes before faxing a couple of referrals.

Fast forward to today, the patient has been in the hospital for 3 days and because she wasn't really admitted for anything legitimate, medicare isn't going to cover her hospital stay and even if they did, they wouldn't cover anything over three days. Which means it comes out of pocket, and these consults aren't cheap. And since it's Friday night and she still doesn't have placement in a nursing home, she's going to be here all weekend. Also, if anyone had talked to the patient for any length of time, they would have figured out that the reason she was depressed was because her husband of 65 years had died 2 weeks ago. Correct me if I'm wrong, but bereavement is a pretty normal thing and doesn't require medication, especially since most of the psych medications cause drowsiness, which increases the number of falls in the elderly. Speaking of which, I really don't think we needed a geriatric assessment to tell us that this 88 year old lady with a broken patella and a broken wrist is a fall risk. And when you're in a long-arm cast, it's hard to do physical therapy on your wrist.

I'm not trying to sound callous, but now the family is mad because they have to pay for this pointless hospitalization, the patient is mad because things have grinded to a standstill and she'll be here all weekend, Dr. Anal is mad that she's not in a nursing home already, psych is mad about the crap consult, and really, what the hell was everyone expecting? It's a hospital. By this point even I have figured out that simple things become big, long, drawn-out processes in a hospital. (if you don't believe me, try ordering FFP, STAT. Oy vey.) I tried telling Dr. Anal that I thought his plan was a bad idea since the patient wasn't suffering from depression and it takes longer than 12 hours to get a spot in a nursing home, but since he's my attending, I tried to be subtle and tactful about mentioning that. By which I mean, he said "admit her overnight and consult discharge planning for nursing home placement and consult the hospitalists for depression and discharge her tomorrow morning when that's all done" and I said "OK." In retrospect, I can see why he misinterpreted my answer and thought I was agreeing with him.


  1. Pathology resident here. There are actually relatively few indications for the proper use of FFP, so one of the reasons it takes so long is that most people have ordered it for an indication that they'd be better off ordering a different product. Also, it takes a long time because is it FROZEN and has to be thawed at 37 degrees for at least 30 minutes. Any hotter and you start to break down coagulation proteins. So, even without all the administrative checks, it's not exactly a STAT product...

    1. Another pathology resident here. You took the words out of my mouth haha. Where's my FFP?? ...in the freezer...

    2. "There are actually relatively few indications for the proper use of FFP"

      Well, yes, that's true.

      Unfortunately one of the few is "bleeding," which is quite common.

    3. So what would you recommend for the very common scenario we see of an old person on Coumadin who fell, bumped her head, and now has a subdural?

    4. nowadays, there is a shift toward using prothrombin complex concentrates (eg. Octaplex), which can reverse INR within 20 minutes or so, and are not - as far a i know - associated with some of the adverse events you see with FFP (e.g fluid overload, TRALI). Although, just a caveat, while PCC has been shown to improve INR reversal, the data on improvement of actual clinical outcomes is much more hazy. And it's a few thousand $$$ per dose. And it doesn't work with the newer oral anticoagulants (like dabigatran and rivaroxaban).

    5. First path resident again. "Bleeding" is not an indication. "Bleeding due to a coagulation factor deficiency" is. The case that Fizzy describes is a good example, since there are specific coagulation factors you are replacing with the FFP. However, as Anonymous 11:32 mentions, it can be a big volume load, and if the INR is only minimally elevated, FFP really won't be doing much.

      I guess my main point is that I do feel really bad that I can't get the product to people quicker. I realize that these situations are emergent and very stressful. However, I also want people to understand that it takes time to prepare the products for transfusion. Coming into the blood bank and yelling at the staff doesn't help plasma thaw any faster.

    6. Thank you Anonymous 8:00 -

      Please don't call on the phone and yell at me in the blood bank. It will take longer to get everything ready, because I have to stop and answer phone calls from the nurse, attending, resident, and secretary. I care about your patient too and I'm doing everything as fast as I can.

    7. Love the wedding singer reference

  2. yep - sounds about right. i'm an ER doc, and i'm a pretty aggressive discharger of elderly patients without a clear reason for admission - i.e. one for which i can envision some sort of intervention/benefit from hospitalization - specifically for this reason. Old people with vague reasons for admission tend to stay the longest. Although, sometimes, the patient really is too frail to go home and live independently. Which makes me wonder, where could the patient have gone safely (with a knee and radius fracture) while waiting for a nursing home bed? That becomes the issue a lot of the times; the hospital is not a good place for these very elderly patients, but there's no where else to put them.

    i sincerely hope i don't live to be 88.

    1. Hospitals should never double as halfway houses for people who can't safely go home, but they do because hospital staff must flag folks as unsafe for home discharge. Your aggressive discharge approach is essential to prevent nosocomial infection and iatrogenic disease -- and it's the approach I would want you to take with me or my parent.

      However, it may not protect you from a bloodthirsty lawyer who takes the case of an elderly person who has a bad outcome after going home, which is inevitable as it's a fact of life that through the fault of no one at all, old people sometimes have bad outcomes at home.

      I don't look forward to being old in our society.

    2. I want to thank you for "having my back" and being a good friend to me
      while I was on this blog. I'm not going to be posting anymore, but I
      felt I owed the courtesy of saying goodbye. Thank you PGYx for
      just being you. - Paul

    3. Paul, I hope you won't let a couple of snarky folks get you down. Plenty of others (on- and offline, I'm sure) value your straightforward, authentic approach. I view this as one benefit of Asperger's. The most genuine people often have thinner skin, which makes them more sensitive to others needs but also more vulnerable to hurt feelings. In a world where too few of us say what we actually mean, I appreciate not having to wade through layers of bullshit just to have a basic conversation. To that end, I hope you'll try not to let the assholes of the world get you down. Best, PGYx

    4. Thank you for all your kind words. They are greatly appreciated. I don't want you to feel badly about a couple of snarky comments directed my way. I'm used to it, and it is not the reason I left. I have a tendency to want to "fix" things and in doing so, tend to overdo it. I was dismissed from a volunteer job for this very reason. I broke the rules by paying a utility bill for some of the hard luck cases too many times. I have a modest income, but I also understand that people need electricity!
      I know it would eventually cost me my position, but I just couldn't do
      otherwise. Unfortunately, I didn't learn from experience and tried too
      hard to make everything nice here. However, this is a Dr. Fizzy Blog and
      not a Dr. Fizzy and Paul Blog. I needed to be reined in and those snarky
      comments only confirmed what I already knew. I will continue to read
      the Dr. Fizzy Blog, but it's best that I stay out of it. You're a great person
      PGYx and a sensitive soul. To you and the rest of the Dr. Fizzy Blog
      family (you too Dr. Grumpy), Be Blessed. - Paul

    5. Paul, you might want to consider starting your own blog. I could put up a link to it in the sidebar if you'd like.

    6. Paul, I respect your reasons and also would definitely follow your blog! I had a little blog but closed it when my desire to be professional and not offend led to the most boring posts possible. Other docs like Fizzy manage to be appropriate while still making me want to read, which I view as a real achievement!

    7. That's the nicest thing you've ever said to me, Dr. Fizzy, and thank you
      PGYx for your kind words too. I'm not comfortable running my own Blog
      due to my own issues (Aspergers) that makes it hard for me to filter out
      certain comments, if you know what I mean. However, maybe the answer
      isn't giving up, but just adjusting down. With your permission, I will limit
      my comments to a maximum of 2 per thread. I will also try to be less
      pedantic, and try not to irritate people with my know it all way of
      expressing myself. Personally, I don't feel I'm better than anyone.
      God made me this way, and it's the only way I know how to be.
      I can do better, though. How about it, Dr. Fizzy? A limited participation?
      - Paul

    8. On second thought, I think a forum is probably a better setting for me.
      However, if I ever do get the urge to post here, I think it's best
      if I limit it to 1 comment/thread. - Paul

  3. So does this constitute an anal hand job?

  4. You are an MD (but not yet board certified). As a doctor, can you say "I disagree with the management plan for this patient, and I won't do it? I want to do this instead, but I won't do what you proposed."

    Are you allowed to do that? (I understand the attending wouldn't be happy- but are you allowed to do so)?

    1. That's about as common, and about as practical, as refusing an order in the military.

      Depending on your attending's mood, that refusal could lead to months of administrative crap or you could simply be out of a job and potentially out the 10+ years you have spent working towards board certification and a "real job."

      I.e., refusal is best left for immediate life threats to the patient. A possibly unnecessary admission does not rate. And you have to be careful, as a learner, in placing 100% confidence in your subjective judgment over your attending's. Even the dumb ones have been at it longer than you, and sometimes in medicine the smart thing looks like the dumb thing and vice versa.

    2. What Tracker said. If an attending has an idea which is in the resident's opinion harmful but not an imminent threat to life or limb, the conversation might go something like this: "for my education, how do we expect x to benefit the patient?" or "for my education, what are the management options we have to choose from based on the results of test Y?" or, in a case like the above: "considering that she needs supervision, but not acute hospital level care, what if her family could look after her for a few days while she is at home, and we ask her PCP to follow up on the depression?"
      Queries like these will sometimes get you somewhere with an attending who respects your judgement and has some sense of his own fallibility,but most of the time they will be a waste of time, which means you will be over duty hours that week (more administrative hassles),
      Part of the problem is a system of complex and perverse incentives, in which a specialist who is booked 3 months out in the outpatient office must see an inpatient within 24 hours, and qualification for acute rehab is based partly on length of stay rather than, you know, the patient actually needing rehab.

  5. Ah Fizzy too funny. I got the last word with my internist. She said I love my job. I basically gave her the same admin crap list/scut work reasons that one would not want to be a doctor: and used a similar circumstance.

  6. "I tried telling Dr. Anal that I thought his plan was a bad idea [...[ I said "OK.""

    I've been there so many times. I laughed aloud. How ridiculous we are when expressing disagreement.

  7. As a newbie in this profession the "military"-type chain of command scenario is a little daunting. But as a newbie type (and a once and future patient) it is also, overall, reassuring. I do not want to have an outsized vote in most medical decisions because I am just not qualified too. Unfortunately, medicine does not allow everyone involved in care (including nurses, social work, etc, etc) to have an equal vote in practical/common sense areas - where everyone is equally qualified to say "in my experience, patients like without a medical indication for admission do not benefit from these stays" … Alas. I absolutely see the need for the hierarchy when it comes to medical/clinical decision-making .. It's too bad the common sense stuff defaults to doctors when often nurses have the absolute best perspective on this sort of thing. … Just a thought. ...

    1. Apologies for the many typos in that comment - I am in the newbie and therefore sleep-deprived portion of my medical education … Which is another safety issue in itself. When a former English major can't choose the right "to/too" how can this person make good decisions about medical care? … Worries for another day.