Dilemma that warrants an adult discussion. Be advised, post is long as War and Peace

[Tobra]

Dilemma that warrants an adult discussion. While I realize this has been a difficult subject to debate without degenerating into heated argument, I am optimistic that will not be the course this thread takes.

I have an example that I feel nicely illustrates a lot of the challenges we face regarding healthcare delivery in the United States. People go to the hospital and are waiting for care in the Emergency Room for hours, overnight even, sorry no beds available. Hospital care is very expensive. People look at their bill and it is eleven bucks for an aspirin, bandaid, or whatever crazy example you care to cite. Bear in mind when considering this, what is billed is not what insurance companies allow, and allowed charges are usually not paid at 100% If you have suggestions for the insurance companies or healthcare providers screwing people out of money, please take them to another thread.

I have been involved in the care of a guy who happens to be about the same age as I, on paper anyway; IRL this is not the case. He is a homeless diabetic crystal meth aficionado. Had a hole that went all the way through his foot that was filled with rotting tissue. Came in septic, where you are over whelmed by infection to the point you are fixin' to die. His situation is complicated by the HIV and Hepatitis C infections he has. Not only that, but he also is being treated for colorectal cancer. Had surgery, done by the local bad ass MFer oncology surgeon. Consequence of this is a colostomy, which is the side exit for the poop, radiation and chemo ongoing, the whole nine yards.

As I said, he has a fetid hole in his foot when I meet him. Initially refused surgery when I talk to him Monday at 0800. I let the doc managing the patient know he said GTFO to me. He gets the ortho hospitalist to go see him, patient told them okay do surgery tomorrow. Tuesday morning he tells the other guy to F** OFF, so they call me to see if I will try and talk some sense into him. I go by and he is all ready to go get this foot fixed, I want to do whatever it takes, don't want to lose this foot. I tell him he needs to do like I say, or the next guy he sees will be cutting off his leg. Clean the rotten stuff out, flush a ton of irrigation through it, put a wound vac on it, and it does surprisingly well post operatively, considering how poorly he followed instructions. He walks down stairs to smoke cigarettes a bit more often than is therapeutic.

The wound vac did not work out, kept losing the seal when he walked on it. I was apparently unclear when I said, "Pretend like that foot is gone, don't even touch it to the ground, or you won't have to pretend, you lose the leg." Still did pretty well, all things considered, even without the wound vac, which would have healed that thing up far, far more quickly. Typically, the patient goes to a convalescent facility shortly after this sort of surgery, much more economical than a hospital. Nobody will take him though. Any facility that might, knows better because this guy has a habit of walking away from care facilities, or being verbally and physically abusive to the people trying to help him. Due to his diseases, he is in an isolation room. Due to his temperament, he is in a hospital, rather than a convalescent home. A week after surgery, the police came to talk to him, because after he declined assistance changing his colostomy bag(B*tch leave me alone). He was not successful in his efforts to change his colostomy bag, so he shat the bed. Nurse's aid comes in to change the bedding. "I need you to move so I can put clean sheets on your bed." He goes off on her. She could ask him to move, instead of telling him what to do, GTFO B*TCH, leave me alone. He is literally laying in is own feces, that are infectious with HIV and Hep C virus, over and above the basic nastiness of cleaning up crap, and she needs to put clean sheets on the bed for him. He tells her GTFO, I have a gun in that drawer, leave me alone. So she leaves and calls security. Security calls the cops. I get there between the time the cops were called and they arrive. He has his feces on my dressing. I am not okay with that, so I am in the midst of changing the dressing when the security guy comes back from calling the cops, I am just getting started. Security guy is a large young man, and stands in the doorway watching while I am doing my thing, which I found a little unusual. I was not hip to the fact he claimed he had a gun, which I would not believe for a second if he made the claim. If that guy had the dough for a gun, he is going to be a high MFer 10 times out of 10 before he purchases a fire arm, say if he found a gold Krugerrand in his Christmas stocking, he buys a bunch of dope. Patient was griping before we started about how much his foot that is so numb he can walk on a hole in the bottom the size of a silver dollar and not bat an eye, is going to hurt when we change his dressing. I did not tell him the nurse had morphine she is about to give him, more so he is less unpleasant after I leave, than for any pain he is going to claim to feel. I am starting to wrap things up when John Law arrives. He asks the guy why he is threatening people trying to help him. Guy denies it, she did not hear what I said, there is gum in the drawer. I say, "You threatened her with a stick of gum, really?" He does not need any assistance, holds his hand out like a traffic cop would and gives me the please don't try to help me look. Guy claims has not been abusive or threatening, which is a lie, because he does not want to get handcuffed to the bed. It probably would not occur to you that you might get handcuffed to a hospital bed, unless that sort of thing has happened to you in the past. Cop asks if he has any warrants, he says no, I have not been arrested in 35 years, which I am confident is also a lie. Cop tells him he does not want to have to come back here again, talks to the guy a bit, then takes off. 5 minutes later, cop returns, to stress that he does not want to hear any more abuse complaints, or he will make life rough when he gets out of the hospital. Patient asks if he really walked all the way back up just to tell him that. Yes, it is that important, so I came back. These people are trying to help you, don't give them a hard time, or I will give you a hard time when you get out of here.

Day after the stick of gum incident, he tells his nurse he is going to leave in two days, and will then return, rather than stay in the hospital and get IV antibiotics. Few days later, he is gone.

Police bring him back a few days after he left. Report read disheveled, incoherent man stumbling around leaking something from his side. A cop sees that and is thinking, "That guy got shot." Turns out it was not a GSW or blood, fecal material, remember the colostomy thing. Foot got a lot worse while he was off smoking crystal meth, bone sort of disintegrates with infection, radiographs are quite impressive compared to the prior to going walkabout views. He currently has osteomyelitis(bone infection) in his first and second metatarsal heads. To get it to heal, and stay healed, would need to take off his forefoot, right behind where the toes attach to the foot. He declines, if it was only the toe, okay, but he does not want half his foot cut off. I read him what the infectious disease specialist had to say, which is pretty much what I have been telling him. He has spent about 42 or 43 of the last 50 days admitted to the hospital. He is going to be in a hospital isolation room for the foreseeable future. He has left AMA(against medical advice) from an acute care facility at least 4 times in the last couple months. His care for the last few months has cost literally millions of dollars. He is not going to "get better" as long as he keeps bailing in the middle of treatment. Taking care of this guy is like Sisyphus pushing a rock up a hill.

I suggested we have him arrested for assaulting the staff, which would apply when he is flinging his infectious poo. If he is incarcerated, he can't very well leave AMA. I was told this would not fly.

This guy is not unique, and this sort of thing takes up inpatient beds from people that would almost certainly benefit more than this guy, who technically does not need to be admitted to the hospital, but no other facility will accept the patient as a transfer, so he stays in an isolation room in the hospital. I am not that interested in operating on this guy, but would because it is the best shot to salvage the leg. If he loses the leg, odds are he spends the rest of his days in some sort of facility, a hospital, given past experience. That would be pretty messed up, and very expensive.

What do you do with a patient like this? His past and current actions have had a significant negative impact on his health. Should this color the decisions made on his care? Should you you take his abusive and assaultive behavior into consideration? Do you continue to do everything possible to try and help them, despite their self destructiveness and non-compliance? Should you somehow try to compel their compliance, cuff them to the bed and refuse to let them walk around, smoke cigarettes? Should their care be somehow reduced or restricted? Resources are not limitless. This guy's pharmacy bill alone is sky high, Daptomycin ain't cheap. I don't know what anti-retrovirals cost for HIV, or the going rate for chemotherapy for the cancer is, but they are pricey, no doubt.

I don't know that an answer is even possible. I am talking about one guy, but it is not one guy, it is maybe thousands of guys and gals.


Sorry this post is like War and Peace long, but it has been on my mind.

[E38Driver]

Here in Tennessee the hospital by me has a sign that says if you are disruptive to the staff they will kick you out of the hospital and they will only treat you in ER and then kick you out.

They do not play here.

As far as you PT. you can only do the best you can then he needs to do his part. If not tough ****. He will die and it is not on you.

Dave

[KFC911]

I read every word and have nothing but respect for what you do for your patients Doc. I have no answers and thank you for giving
a damn....for those that don't....because I don't think I could .

Don't let it get to you...

Best...

[LWJ]

1. Thank you for your compassionate care. Even to those who are not deserving.

2. There isn't a good answer to your question. We live in a democracy. We have a level of decency and care that we strive to deliver. This is the cost we pay.

3. Not that I do, but, if I ran the world, he may not receive such stellar care.

Thank you again. I hope your vent helps.

[Bill Douglas]

Thanks for looking after the guy.

But he's going to die of something very soon. There won't always be someone to help him or make decisions for him.

[herr_oberst]

Reminds me of the episode of MASH where one of the docs has to make a decision to operate on a guy that is so badly wounded that there is no way that he's going to live no matter how much effort is given, but because of his Hippocratic oath (and because he's a good guy) he knows he has no choice, this, in spite of the other casualties lined up

Of course, that's the prettied up, sanitized Hollywood version of the dilemma. Yours is the low down dirty blues version with the HIV and drug addiction and hospital costs and insurance, and I have no advice to offer you but only my best wishes that you can meet his needs to the best of your abilities and he somehow appreciates your efforts.

Good luck, I hope sharing was cathartic.

[speeder]

Too bad you can't just euthanize the guy and ply your skills on someone a little more deserving. We treat animals better than people in this regard, he should be put down.

We treat everyone in this country, even people who don't deserve it and certainly are not paying for it. Someone can murder 3 cops and if they take him alive and he's shot/wounded, we patch him up and send him to trial. It's better than the other extreme, which would be harsh countries w medieval punishments, etc...

It's a very imperfect world but our system is better. It still sucks sometimes, though.

[tabs]

Are you sure it isn't Dipso? Sounds like Dipso.

[tabs]

At some point you have to cut your losses and walk away from this guy. He wants to die..

[ckelly78z]

It sounds like this guy has 10-12 separate problems that all will eventually kill him if not cared for. If he isn't concerned about them, why should we be concerned ? I never took the hippocratic oath, and believe people should suffer from thier own choices, and not needlessly burden the health care system with futile attempts to rectify the situation.

Another fine example of this thought process, would be NARCAN recipients...let Darwin's law rule over these cases, rather than using MY money, and all of the hospital's resources to revive a hopeless case that will repeat itself next week.

My empathy slims considerably over those who won't help themselves.

[DanielDudley]

Sounds like the real problem is addiction. The rest is just symptoms.

I don't do as much counseling as I used to, and I no longer try to help them all because they need it, or even because they want it. I tend to help the ones who will do the work. It isn't fun telling someone that you aren't going to watch them kill themselves, but I have seen enough people do it, and I am not going to hold your hand for that. I can't make someone live, and I won't watch them die. How fun is that?

In your case, it would be pretty easy to have the guy declared a danger to himself and others, and possibly have him committed. Or you can offer him the choice in very clear terms and let him walk away if he wants. Just be very clear that You cannot save him unless he takes steps to save himself, and understand that none of this is your doing.

If there is some kind of agency you can pawn him off to, where he can be incarcerated and receive forced treatment, I expect that would be the only thing that might get him healed of his wounds, which again are only a symptom. As a doctor of the body, you are IMO fighting a lost cause.

You didn't cause this, you can't cure it, and you didn't create it. None of this is your doing. This guy isn't even clear enough to make his own choices. If you truly want to help him, you have to put him where he will receive enforced detox and care, knowing that the end result may still be the same.

Again, if people come to me for help, it is going to be on my terms. From experience, I know that this is the only way it will work. I don't tell people to go to hell, I just tell them I am not holding their hands while they walk to the gate. I tell them it is a clear choice of Life or Death, Good or Evil. I invite them to choose life in very clear terms.

FWIW, I have never refused help to someone who tries, even if they fail. But you have to try. It doesn't always seem fair or right, but there it is.

[KFC911]

^^^^ Why I still visit PPOT after all these years....the people behind the posts.

Thank you Daniel...

[wdfifteen]

I read the story, and I am at a loss for a solution. Seems the guy has a mental health problem that is keeping him from getting physically healthy enough to be able to deal with the mental health problem - catch 22.

[flatbutt]

Toby, is there a legit way to have a psych eval done? Is he a danger to himself or anyone else? If so maybe he can be treated as involuntary in patient?

IDK anything about medicine and law but sounds to me like you are performing according to your oath and conscience.

[jhynesrockmtn]

One of the programs I run is a representative payee social service. We have about 800 clients in Spokane and manage their social security and VA disability payments when they are deemed incompetent to do so. These folks range from young adults with developmental disabilities and mom and dad are tired of the fights over money to the most down and out street folks. We have some pretty good physical security in the office and it has paid off many times when folks have behaviors that escalate. The police and local EMT folks know our location well.

Thank you for your service to this person. The combination of mental health and addiction issues is baffling. I have no real answers other than the folks that are non compliant and impacting public health and access to the community should be incarcerated in some way. They live on and pollute public spaces and are in continual cycles of jail, emergency room, mental health inpatient and then turned back out on the street for it to repeat again. Many are veterans. As they age they are prayed upon by the young street punks. The shelters won't take them any more as they've been kicked out of them all.

[jhynesrockmtn]

Originally Posted by flatbutt

Toby, is there a legit way to have a psych eval done? Is he a danger to himself or anyone else? If so maybe he can be treated as involuntary in patient?

IDK anything about medicine and law but sounds to me like you are performing according to your oath and conscience.

The problem with the harm to self and others test is that it is almost never triggered. I would say a person who continually cycles in and out of jail, ER, psych hospital and inpatient treatment qualifies but if they haven't tied suicide and don't assault others the answer is no. Yet they live in public spaces leaving human waste and garbage. They panhandle and scare folks away from our downtown core which impacts small business. They take up resources that could be used by folks trying to get help. They take the cops away from working property crimes because they have to be street social workers. The list goes on......

[svandamme]

induced coma?
he can't run off or assault staff if he's not awake

[Sooner or later]

Originally Posted by jhynesrockmtn

One of the programs I run is a representative payee social service. We have about 800 clients in Spokane and manage their social security and VA disability payments when they are deemed incompetent to do so. These folks range from young adults with developmental disabilities and mom and dad are tired of the fights over money to the most down and out street folks. We have some pretty good physical security in the office and it has paid off many times when folks have behaviors that escalate. The police and local EMT folks know our location well.

Thank you for your service to this person. The combination of mental health and addiction issues is baffling. I have no real answers other than the folks that are non compliant and impacting public health and access to the community should be incarcerated in some way. They live on and pollute public spaces and are in continual cycles of jail, emergency room, mental health inpatient and then turned back out on the street for it to repeat again. Many are veterans. As they age they are prayed upon by the young street punks. The shelters won't take them any more as they've been kicked out of them all.

Well said.

[tadd]

Guess my question would be, who was paying?

My wife has been a critical care nurse for 30 years and went to nursing sup (runs the whole house at night). The craziness of what people can get away with is nuts.

A hospital is not a hotel. Hospitals getting reimbursed off of patient satisfaction scores is nuts. Should be one question. You go home alive? 100% satisfaction.

I'm almost to the point that we need to move to a pay for fee services. Doesn't matter if it is cash, insurance, credit card, whatever...BUT no pay, no service. Can't go the grocery store and get food without payment. Nothing else in this world can you get 'for free' (as in beer).

Modern medicine is an amazing thing, but we truly need to start dying to appreciate it more.

Just like we need a good plague to remember to vaccinate. Or taking a nuke out into the pacific, calling the press, and doing a public detonation - remind ourselves in this generation what other generations have learned the hard way.

[911 Rod]

You can't save them all Tobra.