More of the same for me last night, lots of sick patients. Acute pulmonary embolus in a patient with an MCA aneurysm with subarachnoid hemorrhage 3 weeks ago. Recurrent CVA in a 44 year old guy. Recurrent colitis in a guy who was told he had Crohn's disease... and then told he didn't. Yea, a pretty routine day.
In any event, I had another patient with a broken hip. She had fallen a few days before, and I guess was moving less and less, which is what prompted the family to bring her in. She was clearly confused, saying it was Tuesday and that she was in the police station in Yonkers, New York (we're at a hospital in Sin City, and she's lived here for 20 years). There was no family at bedside. I figured I ought to call the family. So, I check the facesheet (has all the patient info, including emergency contact info) and call the phone number. It was Arby's... Yes, the fast food roast beef place (with wonderful curly Q seasoned fries)... I thought I misdialed, and tried again... Indeed, it was Arby's! Turns out the number was incorrect (ya think?!). I call the insurance company (benefit of working for an HMO I guess), and get the right phone numbers.
I suppose I could have just admitted her, and things could have been ok. It would have been a lot faster for me just to admit and be out of the ED. But how would I know whether or not she had a syncopal event which led to her fall to cause the hip fracture? How about allergies- can I even trust the facesheet if the phone number is incorrect? Has she had a surgery before? Did she tolerate it well? Lots of questions... which were answered by the daughter.
Although to be honest, I really did want some curly fries.
Saturday, January 31, 2009
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Doc, I would have quit long before you did. Admit the patient. "ROS" unobtainable due to acute delirium. PMFSH unobtainable due to acute delirium. HPI obtained from available sources in the ER and transfer records. Full physical exam. Evaluate lab, discuss with the ED MD and look at the EKG. Document "EKG tracing personally reviewed"
Bills out a 99223 high level H&P.
Next.
I am impressed that you cared. Bonus points to you.
Happy, you really sound like some of the doc's I worked for previously...more concerned for their pockets than correct information. But you probably aren't making the bonuses they were.
Neon, you mistaken caring medical care with the rules and regulations of the Medicare National Bank. Medicare says I don't have to call the insurance company to hunt down the daughter in order to bill them. And if you think I work for free, then you are clearly misguided as well. My time is not free for the taking. If you don't like the rules that Medicare built, I suggest you contact your Congressman or woman. What I described was what I needed to document in order to get paid.
Certainly, one order of business would be for me to write an order for the ward clerk to contact the patients primary care doctor and obtain progress notes, I have no business wasting my time doing remedial phone calls that can be handled by a clerk. My time is better spent taking care of patients. H&Ps, labs, and any other pertinent information I needed to do my job arrive, I review them on my time.
Neon, I ask you this, If I was on the phone spending an hour with the insurance company, while your mother was in the ED in deep distress waiting to be admitted by me, the hospitalist, who is off talking with insurance companies about information that has no acute bearing on the care I provide, would you still consider me uncaring for not coming down quickly to see your distressed mother?
There are only so many hours in a day. If you believe me not calling the insurance company is a sign of not caring, then you are clearly misguided with the reality of health care delivery in this country.
I didn't see that it took an hour with the insurance company to get that information. I get the CMS rap. I work with them daily. Trust me when I say there are problems - and not all is the fault of Medicare. Providers need to be more responsible for their actions, but that is for another blog.
Oh...and I have seen what happens on both sides of the fence. Having a provider that is willing to do the extra bit vs. someone who doesn't give a shit..I'll wait for the one who cares.
I know a hospitalist who occasionally calls a patient's PHARMACY for accurate pre-admit (home) drug dosages. I've never done that in 7.5 years as a hospitalist - don't have the time - and my patients haven't been hurt because of it.
And just because a pharmacy gives you a drug name and dose, that's no guarantee the patient is taking it!
neon- it probably took me another 5-10 minutes to call the access center (i always call to verify eligibility on patients i'm called about from the ed) and get the phone numbers. maybe another 10 minutes on the phone with the family.
i do see happy's point though. i actually have a rounding nurse (clinical nurse specialist/rn) during the day (830-530) that makes most of my calls- outpatient doc follow ups, making sure patients get meds filled, check up on patients a few days later, set up family meetings, call consultants if it's not urgent, etc. he/she makes my life easier so that i can get what i need to get done. i also have my own social worker (separate from the hospital employed people) that can do things like this for me as well.
but clearly, i know how to use the phone when necessary. :)
follow up on the patient:
so, preoperative work up was ok. nothing glaringly abnormal (normal ekg, basic metabolic panel and cbc within normal limits). even had a pre-op echo with a good ef and no effusions (i could argue that she didn't need the echo, but anesthesia here likes one).
so, she goes to surgery the next day for her hip fracture. rather routine.
they put the dressing on.
flat line, no o2 sat.
instantaneously.
the ortho surgeon pages me. i thought it was just out of courtesy (was expecting, a "hey, gonna put this lady back on med/surg. probably ok to send to rehab in a day or so.")
he tells me he's shocked, figures it was a dvt (pt was at home for 2 days after the fall prior to coming in) that became a pe, or a fat embolism (was not a traumatic hip fracture though).
the surgeon, anesthesiologist, and myself all met with the family in the waiting room.
family was very understanding, saying something along the lines of "you guys did the best you could. thank you."
no anger. no tears.
so, i guess the phone call worked out, since the family knew who i was.
that doesn't make me right or wrong. it's just the way things worked out for me.
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