Wednesday, April 8, 2009

Nursing Home Nightmare

One frequent presentation to the psychiatric ER is aggression in an elderly patient. Usually, a nursing home gets tired of dealing with a demented patient, and somehow they are able to send them to psychiatry. Usually there is an allegation of "aggression" or some such. More likely, they just think our social workers can work miracles and find another nursing home overnight.

Lucky for them, there is a psych ER in this county. Imagine your elderly loved one being sent by EMS to a unit where half the patients are depressed, manic, or psychotic, and the other half high on cocaine or meth.

A recent incident was especially troubling, though not entirely uncommon. First, I will try to capture the phone call between the Nursing Home (NH) and social worker (SW).

NH: Do you guys treat aggressive nursing home patients?
SW: Yes.
NH: Can you adjust their meds so they don't hurt our staff?
SW: Yes.
NH: We have an 80-year old female with dementia that is "being aggressive". We'd like to send her there.
NH: By the way, her son wants her placed in another nursing home. Can you assist with that?
SW: Uh, no. If that's really why you want her to come here, then no, we can't accept this patient.
NH: Okay, Bye.

Whaddya know, 5 minutes later the patient shows up with EMS. Of course, the NH had loaded her up and called for administrative approval while she was in transit. This was a classic dump at 4:30 on Friday afternoon. This means the patient gets to stay all weekend, because there is no social worker on weekends.

When the patient arrived, her condition was terrible. The nurse who triaged her had tears in her eyes. I knew something was up, so I went to see her immediately. Elderly, well dressed lady in a wheelchair, pleasant, but demented. The medial (inside) part of both elbows had ulcers from where they rested on the wheelchair arms. There's no way she's "being aggressive"- she couldn't even lift her arms off the wheelchair armrests! Her toes were stuck together, it had been so long since she was given a bath. There were pieces of gauze on some open wounds on her shins, but the gauze had been there so long that the scabs had enmeshed the gauze and you couldn't pull it off without causing severe bleeding.

The patient was admitted to the medical floor for treatment of multiple metabolic problems as well as those listed above. The NH was reported to the appropriate authorities.

I didn't tell this story to gross anybody out. I've been struggling with this for a few weeks. However, I realized there are 2 important reasons for this post. First, before you place a loved one in a nursing home, check the place out. Visit, get references, do all you can to investigate.

The second reason is, while we do tell funny stories on our blog, our intent is also to give some insight into healthcare in this country as well as into the lives of doctors. Some people have left comments below, ridiculing psychiatrists and ER. The thing is, the funny stories are easy to share and make this lifestyle easier to bear. For every story I share that involves a funny moment, I have ten stories that I could share about the pain that I experience along with my patients and their families. And I love all of them.

Psych doc


MedicMatthew said...

When shopping for nursing homes for a loved one, talk to the local EMS folks. I've worked in several parts of the country and there are nursing homes where I wouldn't leave a rabid dog and there are some that are so amazingly wonderful that I'd like to move into myself, but I'm sure they have rules about keggerators in patient rooms.

Por2gee said...

Being an EMT for 7 years in areas like Boston, I know exactly what you're talking about. Unfourtunatly it happens far too often in every town in every state. I've walked into NH's to pick up a patient and literally had to hold my breath in order to stop myself from throwing up. The sad part is, I don't know how many times I've had patients tell me that I'm the first person in months that's come to visit them that wasn't an employee of the NH. It's sad when the EMS worker or ER Doc has to be the patient advocate bc the NH staff & patient's own family could give a f***.

GingerJar said...

And they wonder why nurses and doctors have "battle fatigue". It's hard to deal with this.

York Student RN said...

In Toronto they have what are called GEM nurses (Geriatric Emergency Management).

They maintain surveillance over a number of patients in nursing homes and are first on call when there's an emergency.

In a recent review of the program they diverted 77 percent of elderly patients from the ER.

Anyway, the bottom line is elderly patients need comprehensive community care well before they need an ER.

Nurse Carolyn said...

I work in a combo acute rehab/long term care facility. In my area we are considered the 'Hilton' of facilities. We have a no restraint policy (both physical and meds). After reading your post I can't decide whether I want to cry or kick some nursing-ass.


tracy said...

That is so very sad. And i, for one, would n e v e r make fun of psychiatrist's.

LivingDeadNurse said...

I hate lazy nurses that can't take care of their pts. i work in a LTC/skilled facility. There was no excuse for for the dumping psych pt cause we don't want to deal with them...not all of us are like that. lol

i have plenty of dementia pts and crazies(coworkers)its called medication. I think the only time we actually had to send anyone out was because they kept trying to escape...needed a locked facitlity...and the crazy lady that would throw herself on the floor and say a nurse thru her...and she tried this at least 6time and one broken hip..anyhoo love your posts and have pass u on to some friends...they are addicted too thanks