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.