Why a patient waited 80 hours in the ER for placement

in Patient | 33 responses

by erdoc85, MD

When I arrived for my shift this am, I was passed off the following patient.

EMS responded to a 50-year old guy laying alongside the Interstate. He had no idea who he was or how he got there. He complained of knee pain and shoulder pain. They were kind enough to tote him to my ER where his evaluation revealed that he had a fracture of his clavicle and tibial plateau (knee). Neither requiring anything to be done except a knee brace, a sling and a walker (since he can’t use crutches with a broken collar bone).

We learned that he had been to our ER several times, homeless and with a history of schizophrenia. On two occasions, he had tried to assault the nurses. On each occasion, he escaped before anything was done to or for him.

After a nap and a meal, he told the staff that he had been working in the oil fields in Costa Rica when he got a call from Brazil that his mother had died, so he was hitch hiking to his home in Rhode Island. While the car was speeding down the Interstate, someone had opened the door (from the outside) and pulled him out of the car, leaving him injured along the side of the road.

So, after he was medically cleared, the mental health people evaluated him and decided that he was psychotic but it was a holiday weekend and all of the intake personnel at the psych hospitals that accept Medicaid were taking the weekend off. The Mental Health and Mental Retardation (MHMR) folks would be happy to return on Tuesday to try and place him somewhere.

Trauma service wouldn’t admit him since he didn’t have any serious trauma issues. Ortho wouldn’t admit him since he didn’t need any in patient ortho care. Medicine wouldn’t touch him since it certainly wasn’t a medicine issue.

So, the guy laid around in our ER for almost 80 hours waiting for “placement.”

Late this afternoon, when we really needed our rooms, we contacted MHMR again and tried to lean on the caseworkers to do something with him. That’s when they informed us that in order to place him in a psych facility, he would have to be freely ambulatory without braces or assistance. The psychiatrists wouldn’t take him since they “wouldn’t feel comfortable” with his orthopedic injuries.

And so he remained the in the ER.

“erdoc85″ is an emergency physician who blogs at M.D.O.D.

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Comments

John Ryan
Don’t worry, this will all be fixed when the health reform bill kicks in. He’ll have insurance so when the government bureaucrats get back from their coffee breaks and vacations and seminars and project briefings, they’ll call right back and tell you to turf him to a primary doc. But then there won’t be any primary docs, but there will be plenty of Minute Clinics, so send him to the local chain pharmacy for followup by a physician-extender. Or if they are at lunch, maybe return him to the side of the road. I’m sure there will be other options, as soon as the new Patient-Centered Outcomes Research Institute gets their $84 million and has a chance to meet. Can’t you just feel that “change that works”?
Visitkarte
This is terrible, but still not surprising at all. I work as a psychiatrist in training in a specialized psychiatric hospital in Germany, and we have another aberration of your problem. Psychiatric patients end up in our care, even when they do have, sometimes life threatening, medical or surgical condition, It’s always a fight to get our patients treated for their ‘regular’ conditions because other doctors don’t feel up to treating people who might refuse being touched, kicking and screaming, because they are delirant or psychotic in some other way.
Medicine is medicine, and we are all people, no matter which part of us is currently sick and in the need of medical treatment. The modern medicine is highly specializes, but we shouldn’t forget that our bodies and minds aren’t. All of our systems are stuck together, so doctors should take and treat the patient for the most important conditions, treating his other conditions ‘on the way’.
Your exemplary patient would have still been orthopedic patient as long as his fractures were accordingly treated and then the psychiatry should have taken him and treated his psychosis. Psychiatrists are doctors, after all, and psychiatric nurses are nurses. What’s the problem?

Smart Doc
Correct.
When patients are admitted to a psychiatric unit it is essentially impossible to get any care for medical/surgical co-morbid conditions.

SarahW
It’s not a popular opinion, I think, but institutions for the mentally ill might solve a lot of problems – humane treatment of schizophrenics is not leaving them to toss themselve out of cars when psychotic, and then to moulder in some ER because there is no other place to stuff them.

Elu
Have you ever been to an institution for the mentally ill? Do you really think that psychiatric patients are treated humanely in state psychiatric hospitals? A close relative of mine was delayed treatment for a life-threatening illness by the team members at his “institution.” The end result? The hospital had to relieve him of half his colon. No, institutions as they currently stand are NOT the solution. They just warehouse ill people, so they don’t inconvience those that are not.

elmo
I think your comments about weekend psych admissions are valid. This has been the poor stepchild in medicine for a generation. Is that news? The issue is lousy medicaid-based care is perfectly acceptable to state administraters. Frankly they are bureacrats, they don’t care. It is all about bean counting and the states are losing beans. This issue is going to get worse with more cost shifting to hospitals and docs as states drop medicaid patients. One of the reasons I usually break out laughing whenever self-descibed “health care experts” like maggie maher waxes poetically (by and large without statistics/studies) about how the new healthcare plan is going to fix our present crises. Frankly it isn’t. Very simply you want to control costs liike the europeans then the only way to do it is to ration like the europeans do and americans will have to accept those consequences. Obama’s plan is not going to do it. It is trying to be everything to everybody and I predict will fail. Though I sympathize with your plight, bagging on medicine and ortho because they will not do a social admit isn’t the answer either. Medicaid (if he were to qualify) would simply deny the admit payment. They do it all the time. Trying to pass the buck to an inappropriate medical/ortho inpatient admission is no more the answer then letting him sit in the ER.
PS: Remember this guy sitting in the hospital bed will prevent someone who really needs it sitting in your ER.
http://www.survivingtheemergencyroom.blogspot.com/ Ron Clark, MD
80 hours in the ER sounds excessive, but unfortunately, it is becoming more common for patients to linger in the ER for days without a final disposition when waiting for social services assistance or placement. Social services often work Monday through Friday 9-5 (excluding Holidays) and the Emergency Department is open 24 hours a day all 7 days of the week.
pcp
This is exactly what currently happens with psych patients with private insurance in my neck of the woods.
aek
Psychosis in and of itself isn’t a criteria for inpatient admission. Was he being medicated for it? How was he responding? (4 days to treat and evaluate in your ED)
Why not get him a bus voucher to get him where he was trying to go with contact info for that RI city’s public mental health agency/ local MH crisis tel info? Did your social workers or the patient contact any family/friends?
It seems that no one is treating this person, like, er, a person. Instead of treating him like a pariah, why not engage with him and actually provide some care in which he participates?
anonymous
I guess things don’t work the same way everywhere. When I was a medicine resident, we were expected to take all the social admits as well as co-manage (i.e. do all the scut for) post-CABG patients and TSFO (too sick for ortho) patients. I guess it’s all about the power struggles between departments in the hospital.
C
There is no place for a person with both mental health problems and physical problems to receive proper care. There is no coordination between mental health care and medical care and as a result those with mental health problems suffer. They end up beside the road, in ER’s or dead.
There is more discrimination against the mentally ill than any other segment of the population. It doesn’t matter what insurance they have or whether they are rich or poor. The chasm that exists between available treatments is so great, anyone who acknowledges a coexisting mental health disorder jeopardizes their treatment for the original complaint, as well as the mental health condition.

Zenfire
There are Med-Psych units at some hospitals. They work quite well.

Greg
I’ve seen this many times in the ER where I work…many psychiatric hospitals don’t take medicaid, and if they do, they are often full to the brim already, so patients languish in the ER for hours or even days. I actually don’t blame the hospitals; Medicaid in IL pays so little that many hospitals can’t even cover their costs, and so lose money on each patient with medicaid they see. But until we start taking mental illness seriously, instead insisting that it’s a fabrication of big pharma or just a sign of bad character, I don’t see this situation getting any better.
Kc
I am surprised the guy wasn’t admitted to Hospital Medicine service. Hospital Medicine afterall is becoming the dumping ground for whatever the surgeons or other specialities refuse.

MedPeds Doc
This is so true. And in my community, the surgeons and subspecialists are so tickled with hospitalists that they treat every internist and primary care doc as a hospitalist and want all patients admitted to Medicine. Unassigned call is a nightmare. Acute STEMI going to cath lab…admit at midnight to the poor on call Internist schmuck who has 20-25 patients scheduled the next day JUST so Cardiology doesn,t have to do H&P, deal with social issues, or disposition patient. I have had to visit the hospital two or more times just to admit a patient because he or she was busy in emergent cath or hemodialysis. Internists and FP, partially because of how hospital medicine has evolved, have become the glorified residents or paperwork jockeys, for the surgeons and subspecialists. It is BS but the ER docs in my community facilitate it b/c we are not as callous and uncaring as our subspecialty colleagues and surgeons and thus don’t fight as hard not to get these patients. Newest trend…orthopedists and neurosurgeons admitting their elective post-op patients to the hospitalists. Soon that will be the “standard of care” in our community, and they will expect primary care to afford them the same luxury. Again, total and unadulterated BS!

lisette
not to mention the big push to shut down state hospitals and “return consumers(!) to community-based care”. since psych beds, especially for patient with medicaid or no insurance at all, don’t pay, few hospitals WANT to have psych units. Those that do, only want mildly self-injurious neurotics, not hard-to-treat psychotics or people with aggression. So we regularly have patients sitting on a gurney in the ER, with a deputy at their side, who have been committed by the magistrate but wait up to 3 WEEKS for a psych bed!
Stalwart Hospital
Undoubtedly, the Medicine service (or, the “Hospital Medicine service, as Kc puts it) was seen as a potential disposition destination for this particular patient. However, people are not admitted TO Medicine (or Ortho, or Surgery, etc.), they are admitted BY Medicine — that is, I have to agree to admit the patient to my Medicine service.
From the case synopsis, I am able to identify issues needing addressing by physical therapy (not on an inpatient basis) and Psychiatry (probably on an inpatient basis). The days of Orthopedic Surgery and Trauma Surgery admitting non-operative, non-multiple trauma patients are probably gone.
When the first item to address on a patient that I admit to the hospital is how to discharge them from the hospital, that’s a pretty good sign that it is not an appropriate hospital admission in the first place. The inability or unwillingness of other elements in the health care system to accept this patient do not in any way increase the appropriateness of this patient as a hospital admission.
I imagine that Emergency Departments should expect more of this as we move toward reimbursement structures where readmissions within a certain time frame are not paid for — if readmissions don’t get reimbursed, then the threshold for hospital admission by the inpatient services will necessarily go up.
I don’t envy the position of the emergency medicine physician in this case.
Smart Doc
Hard truth: Wandering unmotivated schizophrenics do not belong in over-crowded understaffed hospital ERs, which are powerless to treat them. They are a complete waste of everyone’s time and energy, as they assault the staff and walk out.
They belong in the criminal justice system, where they can be mandated to involuntary treatment in forensic psychiatry units. There is no other way for these totally non-compliant chronic psychotics.
Visitkarte
@ Smart Doc
I can’t believe how much prejudice and total lack of knowledge comes out of your posting. Psychosis is per definition lack of touch to reality. Most of the ‘non compliant’ psychotic patient were just simply the sickest patients I had. Every single one of them got better after antipsychotic treatment, and they became more compliant. So what if they stop taking their meds? Can you blame them for doing that? Have you ever tried these kinds of medicaments and felt how it feels like to take them and have your ‘usual self’ dampened and slowed down? That’s basically what the meds are doing, and not all of the patients like the result they get. So they are not psychotic on the meds. But if the meds make them slow and sluggish, I don’t blame them for trying to stop feeling like that.
Our treatments are far from perfect. Some patients suffer worse when they have a psychosis that the others. They have terrifying hallucinations and beg us to make this go away. This are the patients who are most likely to stay on meds (sadly, not even they, I have one patient who relapses over and over again into her terrors because she ‘likes’ only one of her meds, but needs at least two to stay psychosis free (or better, psychosis arm). Until now she stopped taking the second med over and over again (she is not the sharpest pencil in the box) and came back, terrified and needy, begging for relief but not able to accept it. There are, on the other side, psychotic that are rather upbeat when they are acutely ill. Why should they want to feel different? On the meds, they feel bad, and they only get the motivation to take the meds if they see they are otherwise hurting someone they like. If the whole world abandons them, why should they try?

MedPeds Doc
Sad truth is that Smart Doc’s belief is closer to the solution than not until there is a consistently effective treatment for psychosis. A psychotic brain (when more than mild disease) left untreated is very generally worse off than one that is forced to be treated. You can argue otherwise, but the plain sad truth is that there is nowhere near the resources needed to treat our current moderate or severe psychotic populations with nonpharmocologic interventions that allow them more freedom of choice to function on that thin line between compensated or decompensated. Hopefully, in time, that will change. I challenge you to convince me otherwise and wish you could. But again, there are woefully insufficient resources in regards to manpower and funding.

Visitkarte
I’m not talking about non medical treatment of psychosis, because there’s no such thing (if you don’t count electro shocks or, maybe, even more criminal, brain surgery). Fact is, we don’t get the right to criminalize sick people, or maybe you think we need to put severely obese persons in jail and feed those 1400 calories a day and put them on the treadmill until they reach normal weight? Or how about putting smokers with peripheral arteriovascular disease in a padded cell until they quit smoking?
Psychotic people need their meds, no way to say otherwise. I just think, it doesn’t mean they need to like it or they are legally or even morally obliged to the society to take them and to ‘function’. We all might have to live with a bit of ‘crazy’ in our lives, because that what freedom is about. If you want a psychotic person to like his meds, you need to try hard and show them why they’re better off with the meds.
Freedom doesn’t mean being free to chose to comply with your doc but not be able to refuse their prescriptions.

MedPeds Doc
The differences with your above argument is that a poorly controlled psychotic person has the very real potential to hurt other people (see the recent Az shootings as an example) while a poorly controlled obese person or vasculopath is less likely to directly hurt someone.

Visitkarte
It took you quite long to come up with some answer, but I disagree. An obese diabetes is very likely to hurt someone if he gets into hypoglycemic or hyperglycemic shock while driving. If you say that’s farfetched, let me tell you that the chances of that happening are bigger than the chances of a psychotic person to actually hurt anyone while psychotic. I should know, because I’m dealing with highly psychotic persons on daily basis. I’m only 5 feet long and have meager 110 pounds to show for. I never got scared until now, and I have participated in fixating quite a few of psychotic patients. I’m never scared to move around them, because I take basic precautions and I’m nice with them, so most of them like me, even while psychotic.
I know there are chances there to get hurt by a psychotic person, but they are heavily exaggerated, most of the fears are irrational and get fueled by the media. Believe me, you don’t want to sit in a bus driven by a diabetic wit badly controlled diabetes. A psychotic person, on the other side, is quite disorganized and therefore easier to fight off when they attack. Of course there are heavy things like weird powers while fighting invisible monsters… But if a psychotic person has a place to go without being judged or looks as a criminal, it isn’t very probable that they’ll let it get that far. On the other side, the first psychotic outbreak is the most probable to end up bad, with suicide of homicide, and there’s nothing you can do about THAT.

Outrider
Aren’t there any group homes for the chronically mentally ill in your communities? Humane, community-based, and much more cost-effective than hospitalization, incarceration or institutionalization. Of course, who wants a houseful of “wandering, unmotivated schizophrenics” living next door to his McMansion?

Joy
Curious–where do you live, that does have such facilities? And how many beds to they have, relative to population, and/or need? They’re not common in the “big open spaces” areas, any more than they are in McMansion neighborhoods.

http://www.survivingtheemergencyroom.blogspot.com/ Ron Clark, MD
Those patients with mental illness exacerbations often end up in one of two places, jail or the Emergency Department. This is a fact, and in my opinion, the Emergency Department is the more humane venue to care for them, especially if they need psychiatric medications. I spend a whole chapter in my recently released book “Surviving the Emergency Room” (Amazon.com) describing for patients and family members what it is like to be a crisis patient in the ER [Chapter 7: The Crisis Patient: Making the Voices Work for You]. Having a family member with mental illness, I have been on both sides of the fence.
SarahW
Again, as the truth is anti-psychotics have a big downside for patients, even those with any insight into the need for them and consistent access to them – it’s time to admit that “community based” services are NOT what the severely mentally ill need. Nor is it humane to treat people with brain disease as criminals, and put them in a punitive facility that is frightening, cold, hot, scary, with the worst medical services and dinosaur-age medications if they get any.
The answer is to go BACK, then forward. Institutionalize the severely mentally ill in quiet, non-stimulating environments that are safe, as comfortable as is practicable – humane controlled settings.
Due process for commitment is a necessary protection but the standard should be lower than it is now, (essentially crisis “the oil light is on and its too late” treatment for short periods, only to be pushed out and run through another cycle of relapse and acting out).
Long term housing/confinement is really what is needed for the safety and health of these persons and the communities affected by sick individuals. This is, one expenditure we OUGHT to pony up as a society, it is our moral obligation to help the helpless, which isn’t to say that free-roaming schizophrenics don’t have other negative effects on our ordered liberties. We should stop pretending that community based services are any kind of replacement for long term commitments.
jsmith
It’s lying, not laying.
jsmith
And it’s lay around in the ER, not laid around.

gzuckier
True, if someone is laid in the ER, that would indicate serious problems with the hospital.

Amy Diver
Another shining example of our WONDERFUL mental health system at work.
I remember the days when there WERE treatment facilities, group homes, and such for these patients. But evidently the almighty dollar is more important than human life and dignity, so group homes and the like closed down, and the patients got tossed out to sink or swim in main stream society.
And now we’re all SO suprised when we hear about cases like this, or cases of mentally ill people commiting all sorts of crimes.
So which was REALLY more cost efficient: seeing to their care, or cleaning up the aftermath?
Food for thought.
pj
Where’s Maggie Mahar to answer the comment made about her by elmo?
She might point out that the “homeless epidemic” with its attendant huge increase in psychotic folks living in the community (in the 80′s I believe) came about right after Reagan led the closing of hundreds if not thousands of mental health facilities….
gzuckier
I would have just sent Mr. Beck to the studio so he could tape his next show.

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