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RustedFox

RustedFox

The mouse police never sleeps.
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3 in a row tonight, now.

EMS brings me 85-95 year old independently dwelling female for "generalized weakness" that wants to be admitted because she "is too weak to walk". One was diagnosed with COVID a few days ago; afebrile, not hypoxic, totally great.
One was supposed to go to rehab today, but for reasons unclear to everyone, couldn't go (BONUS: brings the entire folder of paperwork from her recent admission at hospital somewhere the hell else, where she was admitted for suspected hip fracture and no hip fracture), and one simply "doesn't feel like walking so far in case she has to go pee".

Discharged. Discharged. Discharged. They generally come with family who say things like: "BuT hOw iS sHe GoInG to gEt To tHe BaThRooM? CaN't yOu JuSt ADMIT HeR?!"

No. We are at 120% capacity. We have hall boarders stacked in the ER. Go home. Go fight with your insurer and the rehab facility tomorrow. We're not a hotel. I can't just admit you because you want to check in. Family members will protest that "they can't pick her up!", but there's not a physically fit one amongst them. All of them with their giant bellies and fat legs with fat rolls folding down over their knee and ankle joints. Fat. Fat. Fat. FAT. FAAAAT. Fat. Fat. Fat.

These seniors. They want to live a cushy life, but then don't want to be told that they're soft.

Come on in, hardened Chinese soldiers. The slaughter will be easy.
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Had this very conversation with a patient’s son over the phone last shift. 99 y/o from one the local assisted livings. Came back not 2 hours later after being D/C’d with COVID, allegedly for a fall. No complaints at all, not even a headache. Didn’t even want to go to the hospital. Apparently, the DON refused to call the patient’s family and told EMS “I override them anyway.” Totally negative workup.

“She’s fallen twice, can’t you just admit her?”
“I’d love to, except I don’t have a reason or a bed upstairs to put her in”
“But if she falls and breaks a hip, that’ll probably kill her”
“You’re right, sounds like a conversation to have with the facility or her PCP. Maybe she needs a skilled nursing facility”

Wound up talking to both her sons. To their credit, they were decent people and pretty understanding.
 
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if only there were something like long term care insurance to handle this
 
GonnaBeADoc2222 said:
if only there were something like long term care insurance to handle this
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Except long term care insurance makes health insurance look like a benevolent charity.

“Sorry, you weren’t admitted during a solar eclipse on February 29th, you aren’t covered.”

It is far closer to a scam than real insurance.
 
They throw themselves at the hospital doorstep insisting they can’t take care of them. But at the first suggestion that they look into a nursing home, it’s, “Oh no! He doesn’t need that. We’re doing just fine taking care of him at home.”

Always.
 
It’s rare that we run into reasonable family members because reasonable family members don’t bring their loved ones in for this. It’s always “they can’t go back home but they can’t stay WITH US (exasperated that it’s even an option) until they get a different living situation”. We’re much, much weaker as a society than we were even 30 years ago.
 
WilcoWorld said:
Helps me to keep in mind that these patients and their families aren't trying to ruin my day. It doesn't help me, in fact it harms me, to get angry at them.
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I don't think people are necessarily getting angry at them for coming in. I think the issue comes up when the family refuses to take them home and demands admission despite a full hospital and boarding in the ED.
 
Another RF rant, love it!

Have to agree, I feel lame being forced to admit 'ambulatory dysfunction'.

The best is when you call their bluff and road test the patient, and they end up walking fine lol. k thx bye.
 
Are you guys actually discharging the weak, old gomers that can’t walk and need SNF? If they physically cannot walk I’m normally just stuck admitting them regardless of any other reasons or context.
 
Jabbed said:
Are you guys actually discharging the weak, old gomers that can’t walk and need SNF? If they physically cannot walk I’m normally just stuck admitting them regardless of any other reasons or context.
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I don't think people are discharging people who can't walk. That's an easy dispo. It's the people who come in and can walk that don't meet any medical criteria for admission but demand admission.
 
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JacobMcCandles said:
I don't think people are discharging people who can't walk. That's an easy dispo. It's the people who come in and can walk that don't meet any medical criteria for admission but demand admission.
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Our hospitalists have been giving a lot of push back on these cases lately. We had one in our ED for 2 days until care coordination could place them.
 
southerndoc said:
Our hospitalists have been giving a lot of push back on these cases lately. We had one in our ED for 2 days until care coordination could place them.
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Our hospitalists will admit pretty much anything without pushback but I certainly wouldn't blame them if they said no.
 
JacobMcCandles said:
Our hospitalists will admit pretty much anything without pushback but I certainly wouldn't blame them if they said no.
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Yeah. I could have totally dumped one on the Envision hospitalist service, but when you come with the discharge folder from your stay yesterday with instructions to go to rehab and say: "but I still can't walk! They found nothing and sent me home!", then home you go.
 
Vandalia said:
Except long term care insurance makes health insurance look like a benevolent charity.

“Sorry, you weren’t admitted during a solar eclipse on February 29th, you aren’t covered.”

It is far closer to a scam than real insurance.
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Wait really? Educate me on this por favor.
 
JacobMcCandles said:
I don't think people are discharging people who can't walk. That's an easy dispo. It's the people who come in and can walk that don't meet any medical criteria for admission but demand admission.
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The two shops I work will no longer admit these people without an identifiable reason, even if they can’t walk.

In one place they go home unless there is a strong push from the family/ED staff and that usually involves a 12+ hr stay, the case manager, and house supervisor having to explore all other options. I have pushed in only one instance in the past 3 months (anticoagulated patient who kept falling and was too high risk to stop their AC). In the other shop they board in the ED until placement is obtained by a social worker who may or may not be there. This usually takes 4-6 days.
 
SpacemanSpifff said:
The two shops I work will no longer admit these people without an identifiable reason, even if they can’t walk.

In one place they go home unless there is a strong push from the family/ED staff and that usually involves a 12+ hr stay, the case manager, and house supervisor having to explore all other options. I have pushed in only one instance in the past 3 months (anticoagulated patient who kept falling and was too high risk to stop their AC). In the other shop they board in the ED until placement is obtained by a social worker who may or may not be there. This usually takes 4-6 days.
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Oh
My
God
 
JacobMcCandles said:
It’s rare that we run into reasonable family members because reasonable family members don’t bring their loved ones in for this. It’s always “they can’t go back home but they can’t stay WITH US (exasperated that it’s even an option) until they get a different living situation”. We’re much, much weaker as a society than we were even 30 years ago.
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So, I had this very VERY thought the other day.

When I think back 20 years ago, we didn't have seniors in their 80s and 90s just kicking it solo. Once you you got topply, you went to a nursing home. What happened?
 
SpacemanSpifff said:
The two shops I work will no longer admit these people without an identifiable reason, even if they can’t walk.

In one place they go home unless there is a strong push from the family/ED staff and that usually involves a 12+ hr stay, the case manager, and house supervisor having to explore all other options. I have pushed in only one instance in the past 3 months (anticoagulated patient who kept falling and was too high risk to stop their AC). In the other shop they board in the ED until placement is obtained by a social worker who may or may not be there. This usually takes 4-6 days.
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What if they have no family? They just go home alone? Is it automatic palli so they die or something?
 
RustedFox said:
So, I had this very VERY thought the other day.

When I think back 20 years ago, we didn't have seniors in their 80s and 90s just kicking it solo. Once you you got topply, you went to a nursing home. What happened?
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You are aware that nursing homes have imploded since being taken over by private equity? That many won't take unfunded seniors, and that workers quit en masse during Covid?
 
miacomet said:
What if they have no family? They just go home alone? Is it automatic palli so they die or something?
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At shop 1 we have to try to arrange for a ride home through social work, track down any former friends who can care for them, and hope they somehow roll up the front stairs into their homes. Ultimately tons of hoops to jump through and they often end up being signed out at least once. At shop 2 they just board in the ED until they can be placed, sometimes multiple days. I will no longer be working at shop 1.
 
SpacemanSpifff said:
At shop 1 we have to try to arrange for a ride home through social work, track down any former friends who can care for them, and hope they somehow roll up the front stairs into their homes. Ultimately tons of hoops to jump through and they often end up being signed out at least once. At shop 2 they just board in the ED until they can be placed, sometimes multiple days. I will no longer be working at shop 1.
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Huh, I wonder how shop 1 expects them to, say, get food or get to the bathroom. I guess this is what medmal reform means- the outcome doesn't matter.

I will make sure to show up with no friends/family to the ER so I can be admitted.
 
miacomet said:
You are aware that nursing homes have imploded since being taken over by private equity? That many won't take unfunded seniors, and that workers quit en masse during Covid?
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It was more of a whistful rhetorical retrospective than an actual question, but yes.
 
miacomet said:
Huh, I wonder how shop 1 expects them to, say, get food or get to the bathroom. I guess this is what medmal reform means- the outcome doesn't matter.

I will make sure to show up with no friends/family to the ER so I can be admitted.
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I hear what you’re saying. But inpatient isn’t the solution and admitting these patients means in many cases that true acute illness doesn’t get care due to lack of system capacity. There is no good answer and your indignation isn’t useful either.
 
RuralEDDoc said:
I hear what you’re saying. But inpatient isn’t the solution and admitting these patients means in many cases that true acute illness doesn’t get care due to lack of system capacity. There is no good answer and your indignation isn’t useful either.
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Well, acquiescing and sending them home isn't the answer, either. Clearly, admitting them if no safe DC can be found is preferable to not admitting them. System capacity isn't their fault.
 
RustedFox said:
3 in a row tonight, now.

EMS brings me 85-95 year old independently dwelling female for "generalized weakness" that wants to be admitted because she "is too weak to walk". One was diagnosed with COVID a few days ago; afebrile, not hypoxic, totally great.
One was supposed to go to rehab today, but for reasons unclear to everyone, couldn't go (BONUS: brings the entire folder of paperwork from her recent admission at hospital somewhere the hell else, where she was admitted for suspected hip fracture and no hip fracture), and one simply "doesn't feel like walking so far in case she has to go pee".

Discharged. Discharged. Discharged. They generally come with family who say things like: "BuT hOw iS sHe GoInG to gEt To tHe BaThRooM? CaN't yOu JuSt ADMIT HeR?!"

No. We are at 120% capacity. We have hall boarders stacked in the ER. Go home. Go fight with your insurer and the rehab facility tomorrow. We're not a hotel. I can't just admit you because you want to check in. Family members will protest that "they can't pick her up!", but there's not a physically fit one amongst them. All of them with their giant bellies and fat legs with fat rolls folding down over their knee and ankle joints. Fat. Fat. Fat. FAT. FAAAAT. Fat. Fat. Fat.

These seniors. They want to live a cushy life, but then don't want to be told that they're soft.

Come on in, hardened Chinese soldiers. The slaughter will be easy.
Click to expand...

These patients families are more draining than a 3 hour on and off code.

Take these gomers to the horse doctor.
 
miacomet said:
Well, acquiescing and sending them home isn't the answer, either. Clearly, admitting them if no safe DC can be found is preferable to not admitting them. System capacity isn't their fault.
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People who can’t walk well before they arrived still usually can’t walk well after we part ways. And no deep thinking pow wow with me, some admin flunky, and the underpaid social worker isnt fixing that.
This is hard work and many of us are drowning.
 
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This is inherently a cultural problem I think. If they have family, then they should go home with the family. If she can't walk to the bathroom get her some depends and the family can change diapers at home. Cook for her at home, do all that at home. This is not what a hospital is for. In many countries this is precisely what families do, it's just expected. You take care of your own.

Here in America, we're a bunch of selfish pricks. Why should I take care of grandma when the nurse can just do it? Ridiculous. Now, if there is no family, you're kind of stuck. I don't see how you can send an elderly person who clearly cannot take care of themselves home. Then it should probably be admit for placement. Which is not the best answer either.

As the population ages and there are fewer in the workforce to support them this will become even worse. I just don't see an easy and ethical way out. Things like this is a part of what drove me out of EM. I was either arguing with family who didn't want to take care of their own, or arguing with a hospitalist to admit somebody with no problems except getting old. None of it was relevant to EM as far as I could see, and if it was, then EM was not the specialty I thought it was. So I left.
 
Tipsy McStagger said:
This is inherently a cultural problem I think. If they have family, then they should go home with the family. If she can't walk to the bathroom get her some depends and the family can change diapers at home. Cook for her at home, do all that at home. This is not what a hospital is for. In many countries this is precisely what families do, it's just expected. You take care of your own.

Here in America, we're a bunch of selfish pricks. Why should I take care of grandma when the nurse can just do it? Ridiculous. Now, if there is no family, you're kind of stuck. I don't see how you can send an elderly person who clearly cannot take care of themselves home. Then it should probably be admit for placement. Which is not the best answer either.

As the population ages and there are fewer in the workforce to support them this will become even worse. I just don't see an easy and ethical way out. Things like this is a part of what drove me out of EM. I was either arguing with family who didn't want to take care of their own, or arguing with a hospitalist to admit somebody with no problems except getting old. None of it was relevant to EM as far as I could see, and if it was, then EM was not the specialty I thought it was. So I left.
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Same. It’s why I left shop 1 and cut my FTE in the ED as a whole.
 
Birdstrike said:
They throw themselves at the hospital doorstep insisting they can’t take care of them. But at the first suggestion that they look into a nursing home, it’s, “Oh no! He doesn’t need that. We’re doing just fine taking care of him at home.”

Always.
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RustedFox said:
So, I had this very VERY thought the other day.

When I think back 20 years ago, we didn't have seniors in their 80s and 90s just kicking it solo. Once you you got topply, you went to a nursing home. What happened?
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Unfortunately the sheer amount of guilt tripping and shaming that is aimed at those who do place their elderly relatives into a residential care system these days, often loudly expressed by well meaning but completely misguided friends, family members or random do-gooders, is at an appallingly high level in my experience.

Pre covid I was fortunate enough that my recently diagnosed with mixed dementia, and rapidly declining Mother was able to essentially board in a Geri hospital ward for around 12 weeks (she was also sectioned under the mental health act at the time, so not like she was going anywhere in a hurry from that point of view at least). Once she was semi stabilised she was given a 'trial at home' period, with extra services and visiting carers in place, which lasted just under 4 days before she was readmitted to the Geri ward with Influenza A, severe dehydration, and another section order under the mental health act. At that point she was deemed nil capacity and all medical and financial decision making was handed over to me as her guardian. Given her rapid deterioration with the dementia, and the fact that neither myself nor any of her friends and family were capable of providing the sort of 24/7 intensive care that she needed, naturally I opted to have her placed in a residential care facility as soon as a bed became available.

Now considering the above I was lucky that her still living family members gave their full support and understanding regarding the decision on nursing home care - other people though, not so much. The number of messages I received from people, as well as responses from dementia care support groups, that just outright questioned my decision, & then proceeded to inform me of the error of my ways, was quite frankly more than a little surprising to me. To them my saying that I had arranged for my Mother to go into a nursing seemed to be roughly the equivalent to me saying I'd decided to take her out back and shoot her. :smack::smack::smack:
 
Yeah it's awful the thing is that the ED is what society uses as a safety net. Since EMTALA exists old people and the growing population of older people will go and fill up the ED.

Many relatives will not take care of an older aunt since that means they have to find a place for them and plus do their childcare duties while dealing with inflation.

They aren't going to take care of an aunt who can't walk and deal with non child poop or pee. Bathing and dressing is also a major drain while being at your house.

We need to fund some home health services or have people just stay in a commode bed. This is a society problem it's unfair to just dump it on the ED.
 
It's because there's no incentive not to dump family members in the hospital or find cheaper alternatives. Hospital should give them a estimate of cost per day and sign an agreement to pay the bill.
 
pkwraith said:
It's because there's no incentive not to dump family members in the hospital or find cheaper alternatives. Hospital should give them a estimate of cost per day and sign an agreement to pay the bill.
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They did just that when my Mother had to remain on the Geri ward for an extended stay. Medicare in Australia covered the first several weeks (I'd have to go back through the paper work to give an exact figure), but then after that we were expected to pay a daily rate to cover costs of the bed and any ongoing care. I think we ended up paying about $1500 out of pocket, but we were also lucky that we found Mum a nursing home placement fairly quickly.
 
I have a hard time blaming the folks in these situations in the U.S. As above, basic supports for elderly care are a tattered mosquito net. They're not safe in their own homes. The facilities they go to can be garbage private equity casino chips. Families are struggling to hold it together enough without having to be unpaid carers for an elderly parent.

It's so different here.
 
What's ultimately worse is when a patient after a hospitalization stay arrived at their SNF, does not like it for X stupid reason (such as not giving them their pain medication immeidatly on arrival), calls 911 to bring them back to the ED so we can put them somewhere "better" and eat up more ED time/resources and hospital ED time/resources. I absolutely blame these patients.
 
Tipsy McStagger said:
This is inherently a cultural problem I think. If they have family, then they should go home with the family. If she can't walk to the bathroom get her some depends and the family can change diapers at home. Cook for her at home, do all that at home. This is not what a hospital is for. In many countries this is precisely what families do, it's just expected. You take care of your own.
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This is one thing I truly never understood about America.

It's astonishing too, how many immigrants who come here with nothing and somehow manage to take care of 85yo abuela with no support from the government while essentially being day laborers, meanwhile folks here will call 911, burn $1000 in public funds for an ambulance ride and demand admission because "I don't like my nursing home".
 
Birdstrike said:
They throw themselves at the hospital doorstep insisting they can’t take care of them. But at the first suggestion that they look into a nursing home, it’s, “Oh no! He doesn’t need that. We’re doing just fine taking care of him at home.”

Always.
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Don Ohlmeyer once said "The answer to all your questions is: Money."
 
Don't see the point of being mad at any patient/family for any reason short of threatening or aggressive behavior. They're hurting and they don't know any better, hence we have jobs. Hospitals are so dysfunctional, on a daily basis there are multiple colleagues that piss me off, no need to make the patient one of them.
 
I had a great one this morning. Five able bodied family members said they couldn’t keep granny (who can walk, but they are afraid she will fall) through the weekend and work with a SNF to get her in. I pointed out she’s obviously not going to get placed on Easter. They insisted on admission. Fine. 45 minutes later they’re causing a riot in the waiting room because she needs a bed to lay down!

People have to stop expecting healthcare workers to care more about their mom than they do.

(And I know the system isn’t perfect, but we recently had to arrange home health care for my gramma before she died, and we were able to arrange 24 hour caregiver with like 2 days notice.)
 
CoolDoc1729 said:
I had a great one this morning. Five able bodied family members said they couldn’t keep granny (who can walk, but they are afraid she will fall) through the weekend and work with a SNF to get her in. I pointed out she’s obviously not going to get placed on Easter. They insisted on admission. Fine. 45 minutes later they’re causing a riot in the waiting room because she needs a bed to lay dow
People have to stop expecting healthcare workers to care more about their mom than they do.

(And I know the system isn’t perfect, but we recently had to arrange home health care for my gramma before she died, and we were able to arrange 24 hour caregiver with like 2 days notice.)
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People show the most entitlement when they aren’t paying a direct bill
 
spent way too much today explaining to an elderly person and their boomer child why they dont need to be admitted for constipation and can drink miralax at home. family insisting the patient needs something done NOW on easter night since its been over 3 weeks of constipation. "we have insurance we need to be admitted"
 
As a radiologist I don't know how you guys deal with this **** all day. My M3 rotations where when I realized that the worst part of my day was interacting with patients. Chillin in the workroom writing notes and talking to the residents? Great. Patients and their families? F****** kill me.

God bless you guys. 🙏
 
WilcoWorld said:
Helps me to keep in mind that these patients and their families aren't trying to ruin my day. It doesn't help me, in fact it harms me, to get angry at them.
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They don't wake up one day and say "I'm going to the ER to ruin WilcoWorlds day." However, they do wake up and say "I don't want (or cannot) to take care of grandpa anymore and there has to be someone else who is going to pay for his care. I've been taking care of him for a long time. Someone else needs to do it. He has insurance and that means someone else is going to pay."

And in the ER they come.

I'm not angry at them as I don't think they are being personally and intentionally malicious or malevolent. I am upset at the system and our culture that the answer for many to the problem of "I can't take care of my family" is to "make it someone else's job. Here you go."
 
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