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You Gotta Draw The Line Somewhere
PREFACE: Determining the when, why, and how of health care isn’t always straightforward. When should a patient be hospitalized? Who’s responsible for doing what? How should a final illness be handled? The answers—and approaches to health care—can run the full human-response gamut. Rules and attitudes that don’t always reflect reason or compassion can take charge. Such is the case of a rehab patient seeking a respite admission to a hospital told us by physicians Paul Haidet and Gina Osorio. We hear from hospital staffers focused on moving the patient off their turf (and onto someone else’s) and from others trying to maneuver through a recalcitrant, rule-bound system to ensure that the patient is admitted. Next, registered nurse Veneta Masson recounts the story of her mother’s last days. Taking a determined "less is more" approach, Masson’s mother opts solely for palliative care from home hospice. She sets the rules about how she will die, including that she will remain at home, on her own turf. By insisting on low-tech final days in her own home (and going through the process with as much as grace as possible), she gives her daughter—and us—much to contemplate.
The accident happened in early December. I was driving home and must have fallen asleep; the next thing I remembered was in the ambulance when they were telling me we were on our way to Good Shepherd Hospital. I broke my neck, hip, and leg and sprained my other ankle. I was in one of those halo things on my head and had rods holding my leg together. The orthopedists told me my hip would heal on its own. They said I could stay in the halo for a bunch of weeks, or they could do surgery and fix my neck. I chose surgery because I didn’t want to stay in that halo. During my first week in the hospital, they told me I would need some rehab when I healed from surgery. I was worried because I didn’t have any insurance. When they found out I was a veteran, they said: "That’s good, we can probably get you transferred over there for some rehab." They never talked about it again, though. When Christmas was getting near, they began to say I was "stabilized" and that I could go home. My mom was worried about trying to take care of me, because I couldn’t put weight on my right side and had those rods going through my leg. They told me not to worry, that they would talk to my mom and teach her everything she needed to know. The week before Christmas, an ambulance came and took me home. Things didn’t go well. My dad was old and on oxygen. My mom had to take care of both him and me. I wasn’t supposed to put any weight on my right side, and my left leg was in a cast. My bed was too short for my right leg with those rods in it, and I was cold because the space heater in my room was broken. They sent a toilet home that I could keep in my room, but I didn’t have a wheelchair or anything to get around with. I lay in bed for five days. It became clear that my mother was overwhelmed and I wasn’t going to be able to do this at home. The worries I had when they sent me home now turned to panic. My brother came over on Christmas Eve and we talked about it. Since I was a veteran, we decided to have him take me to the emergency room at the VA [Veterans Affairs hospital], hoping they might be able to admit me and help take care of me. We figured they would probably say no; I wasn’t bleeding or anything. I’d heard doctors call my kind of situation "social," but we had no other choice.
Michael’s brother helped him into our emergency department on Christmas Eve, and I was up for the next patient. Michael was large and physically fit, although lying on the gurney he looked smaller than his 6'1'' height would suggest. At thirty-eight, he was considerably younger than our usual patients; I guessed that he had served in Desert Storm. His calm eyes matched his soft-spoken voice, giving him an air of gratitude as he articulately related the details of his auto accident and his subsequent treatment at Good Shepherd Hospital. He even brought some records from that hospitalization with him—an unusual practice for patients in our emergency department. While Michael’s previous medical history was unremarkable, the various pieces of hardware adorning his frame hinted at the intensity of his recent trauma. The cervical soft collar was evidence of his neck fracture and subsequent surgery to decompress his spinal cord. His right hip fracture had been left to heal by secondary intent. The external rods that had been inserted through his skin and shattered right tibial bone were still in place. He had an air cast on his other leg, too; the nature of his injuries there were unclear, though. Despite being unable to bear weight on his right side, Michael was sent home after two weeks at Good Shepherd. He had no scheduled rehab; had no equipment except for a bedside commode; and was under the care of his parents, who were elderly and infirm. Unable to care for himself and, like many veterans, without insurance, he was now in our department because he had nowhere else to go. I noticed that Michael’s VA paperwork was in order and that he was eligible to receive care from our facility if he had an indication. The problem was that he had no acute medical or surgical problems that would warrant admission; he was, in the common parlance, a "social admission." The easy thing to do would have been to refuse admission. But I felt outrage at Michael’s plight and couldn’t let it go. As a veteran, Michael had served our country, and now he needed our help. I was determined to facilitate Michael’s admission to the hospital. I got on the phone and started making calls. It became clear to me that this was not going to be easy. The orthopedic resident refused me because Michael did not acutely need surgery. The rehab resident refused me because rehab did not do direct admits to their floor from the emergency department. The medicine resident refused me because Michael had no medical issues that warranted admission to their service. But the medicine resident told me to call back if no one else would take him, and she would see what she could do. After spending most of my shift making calls, I was no closer than when I started, and I was getting impatient. I wanted to finish my shift on time, it being Christmas Eve and all. I had nowhere else to turn, so I called the medicine resident back. She said to expect a call from her attending soon.
The ER called me late afternoon on Christmas Eve about a patient. He was an African American male who had been involved in a car accident, had been stabilized at an outside hospital, and was sent home. Apparently, there had been no rehab consult at the outside hospital, and he was unable to care for himself at home. He sounded like he might be a good candidate for rehab, but it was Christmas Eve, and we don’t admit patients to our service from the ER. That’s the rule. Besides, there would be no personnel in rehab to start working with him until the following Monday, so there was nothing that we could do for him right away anyway. He would just have to be admitted first to the medical or surgical service with a consult to rehab. That’s the best we could do. We would see him on Monday, verify that he would be a good rehab candidate, and start to look for an open bed on our service.
I heard about that mva [motor vehicle accident] patient in the ER over at the VA. He wasn’t a candidate for ortho earlier in the day, and he wasn’t going to be any more of a candidate later, either. But there I was, scrubbed in the operating room at another hospital, Christmas Eve, 8:30 at night, and some VA medicine attending was paging me. What did he think I was going to be able to do? I finished my procedure and called him back. He told me about the several orthopedic problems that had already been surgically corrected. Hey, like I said, what did he think we could possibly do for this guy on the ortho service? This was clearly a social admission, and I was already boarding too many people on ortho as it was. Look, I was the only person covering the entire ortho services at four hospitals for the whole weekend; medicine at the VA, by contrast, had seven different teams with at least two to three residents who were in house 24/7. You do the math. It would be way easier for medicine to board this patient than ortho, especially on Christmas Eve.
I am all about the patient. I try my best to take care of all my patients’ problems, both medical and social. Many of the other residents discharge patients from the hospital before they’re ready, but I try to make sure that my patients have a good plan and good follow-up in place before they go. Even though attendings and interns often tell me to go home, I choose to stay or come into the hospital to make sure that everything goes right for my patients. This was my first Christmas Eve away from my family, and my team was on call. I resigned myself to the fact that we were here in the hospital, and I was prepared to take care of any patients that came our way. But the ER crossed the line when they called about the multiple trauma patient. I’ll say it again: I am all about the patient, and I am willing to help out as much as I can, but this guy had no medical problems whatsoever. He was clearly either a surgical or rehab patient, and that’s where he would be served best; that’s where he should go. Besides, if he came to our service, rehab wouldn’t even see him until Monday, and then it would be even more days until they found a bed for him. I’m sorry, but that’s unacceptable. My team could do nothing for this guy. I’m tired of experiencing this story over and over again. "No one will take him, so let’s send him to medicine." I’m tired of never getting respect from the other services. What do they think that we are? Their servants to take care of every situation that’s difficult? Well, not that night, not on Christmas Eve. I had a responsibility to protect my interns. I had to draw the line somewhere. And this guy had no medical problems. The key issue, though, was that as a resident I couldn’t refuse an admission from the ER. But my attending could, so I paged him.
My son and I had just come home from church when I got the page. Gina told me about a patient who had suffered multiple traumas in an auto accident earlier in the month, and now the ER wanted to admit him to our service. He was young and had no other medical issues and no past medical history. This was a classic turf battle; none of the other services wanted the patient on their turf, so they were trying to turf him over to us. Gina needed my help to refuse admission to the medical service, and I agreed. All of those episodes from my own residency came flooding back to me. I felt the lack of respect that I had experienced as a medical resident when many a surgical resident or ER attending had called me down to do their work for them without even saying "thanks." Well, this time was different. I was different. I had power now. I could say no, and there wasn’t a damn thing that they could do about it. I called the ER, full of my own righteousness, ready to throw this back in their face, ready to protect Gina and to right all of the wrongs that haunted me from my past. The ER physician assistant caught me off guard. "Hi, this is Jacquelyn in the ER. I’m so sorry to call you, but I have nowhere else to turn. I’ve been trying to help Michael for most of my shift..." She told me the story of the patient, how he had been discharged from Good Shepherd, how he had no resources at home, how he had no acute medical problems, how she had called every service that could help and had been turned down by all of them, how she was going to have to send him home if she couldn’t find a way to get him admitted. This was not a lazy colleague on the other end of the line, but a caring professional desperately trying to do the right thing. I couldn’t follow through with my plan. I couldn’t say "no." Jacquelyn’s attentiveness to my own feelings and her telling the story of her struggles helped me to realize that the power I intended to use against the ER should instead be directed to help the patient. I asked her to sit tight while I made some calls. I spent two hours on the phone. I called the residents and chief residents of all the services and heard their stories, how the rehab service didn’t admit from the ER, how the ortho service was overworked, how each resident had valid and reasonable points about why it would be inappropriate to admit the patient to their service. No one was a villain, but no one was a hero, either. The humanity of all the doctors was evident, as everyone expressed the need to care for the patient and competing needs to preserve professional identities and limit workloads. I searched my memory for someone with whom I had a relationship and who could help. I decided to call John, our hospital’s chief of surgery. Since I had worked with him on a grant, we had a measure of rapport, and I trusted his opinion. John had been at our hospital a long time, and it was obvious to me that he had been in this situation before. "You know, Paul," he said, "This guy has to be admitted. It sounds like the best place for him to be is in rehab. What I would do is call Bob; he’ll be able to transcend whatever the barriers are." Bob was the hospital’s deputy chief of staff. As with John, I had a relationship with Bob because we were in the same division. I called Bob at home and related the story to him. His response brought relief. "Well, yes, there are rules, but they just need to be bent in a situation like this," he said. "We’ll need to work together to bring the patient in. Since there’s no one from rehab in house now and they would have to come in to admit the patient, let’s have medicine write the admission orders and cover overnight as a courtesy to the rehab service, and rehab will take over his care in the morning. I’ll call the chief of rehab to inform him of the plan." My joy at this success was tempered by my next call with Gina. I thought that she would be happy to do the orders. Instead, she yelled, "This is not fair! We should not be involved in this case at all! Medicine never gets any respect! We do these things to try to help out and do what’s right, and they just keep coming back to us with their work! You gotta draw the line somewhere, and it needs to be drawn here, right now, tonight of all nights!" She was choking back tears. I was feeling tired, frustrated, and helpless. I felt multiple pulls as I thought about the patient, about Gina, and as I looked down the hall at my harried wife, my sick-with-the-flu two-year-old, and my bouncing-off-the-walls six-year-old. What to do? "I hear what you’re saying," I said to Gina. "And I agree that he has no medical issues, but as a hospital we need to work together here. I respect your situation and have been in similar ones myself, so I’ll come in and admit him, and you don’t have to be involved in his case at all." Gina recoiled at this suggestion: "No, you need to be home with your wife and sons—I’ll admit him. It’s just not fair, though." As I hung up the phone and walked down the hall to help my wife, I thought, "No, none of it is."
The situation wasn’t fair, but Michael turned out to be a really nice guy. He and his brother were very appreciative as I came down to do his admission orders. My workload that night was light, and I stopped by later. He looked like an enormous weight had been lifted off of him. As I stood in the doorway looking at Michael, I felt better about the evening, knowing that we had done the right thing for him in the end. I still felt strongly about medicine always being treated unfairly, but my frustrations from earlier in the evening began to dissipate as I sat down to talk with Michael and got to know him a little bit better.
Paul Haidet (phaidet{at}bcm.tmc.edu) is a general internist at the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston, Texas; he is supported by a career development award from the U.S. Department of Veterans Affairs. Georgina "Gina" Osorio is a resident physician in the Department of Medicine at Baylor College of Medicine. The opinions expressed reflect those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs or Baylor College of Medicine. This is a true story; the text is based on the authors’ recollections of phone conversations and on an interview with the patient. All names other than the authors’ have been changed.
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Michael (Patient)
Jacquelyn (Physician Assistant,...
