Tuesday, December 05, 2006

Bang Head Here

In yesterday's post, I wrote of a patient with dementia who is driving me to repeatedly connect my forehead with the nearest wall. Today, my bruised forehead is crying, "Uncle!"

As I described last night, my patient eventually arrived to the hospital after much hemming and hawing. He reportedly made it through the night---with some complaining--after undergoing some bloodwork, a chest x-ray and a CT-scan of the head. This morning, I arrived at the hospital with my Nurse Practitioner colleague and we read through the patient's chart. He was not in his bed, and we assumed that he was downstairs for his brain MRI and lumbar puncture. I noticed some discrepancies in the chart, left a note with my cell-phone number, and we were on our way.

Two hours later I receive a call that said patient actually left the hospital---without a word to anyone---in a cab this morning in the company of his son who had spent the night with his father in the room. That was the first strike of the ol' forehead against the wall. I was then informed that he would lose the bed entirely if he did not return immediately. They had not deemed him a "flight risk" and the examining doc found him "competent". "How could he be competent when he thinks he bought a plane in Puerto Rico yesterday?" I retorted. There was stunned silence on the other end of the line. I banged my forehead again. Harder.

I began to work the phones. No answer at the home phone but I managed to reach the patient himself on his nephew's cell. To wit:

"Where are you? You're supposed to be in the hospital."

"I had to come home. I was going to lose my apartment, and the plane that I bought in Puerto Rico."

"You aren't well, and you have to come back now. Put your wife on, please." I tried to be patient, I really did.

"Hello?" said his wife.

"Why isn't he in the hospital? He's not well. You can't let him make decisions like this."

"I don't know what to tell you," she replied.

"Well, I'll just tell you that he needs to be back at the hospital immediately."

"OK, we'll go now."

I continue with my day, paging the attending doctor that he is on his way back to the hospital and they should hold the room. I call the Infectious Disease doc who deemed him competent and I suggest a real psych evaluation for competency and a sitter in the room for the duration. I also point out discrepanices I noted on the inpatient med list.

An hour passes. And another. My forehead begins to feel better.

My cell phone rings. It's the Infectious Disease doc.

"Keith, I'm afraid I have bad news."

I prepare my forehead for further abuse.

"He came back to the floor, and we told him to settle in his room. He asked if he could go out to smoke, and the charge nurse told him he'd have to wait 30 minutes until everything was in order. When she returned to the room, he was gone. That was an hour ago."

I put the call on hold, brace my hands against the wall, and continue making a lovely dent in the sheetrock wall next to my desk. There's probably chips of paint stuck to my forehead by now. Should I switch to a filing cabinet?

I call the patient again, and the family is at a loss as to why he left again, who was with him, and why they allowed this demented person who thinks he owns a plane in San Juan to leave the hospital. I explain that his chest x-ray was abnormal, he needs a brain MRI, a CT scan of the chest, a lumbar puncture, and his serum ammonia level is high, dangerously so.

"We'll bring him to the clinic tomorrow" is all they say.

"OK, that will have to do." I finally give in. What more can I do?

"He must come in tomorrow to see our infectious disease specialist---no excuses." I hang up the phone.

Oh, my aching head. Maybe I should switch to meditation and abdominal breathing. But the feeling when my head hits that wall is just so satisfying........
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