Author: Real Doctor

Chaos in the Mental Health Center

It was 1978. I was a medical student doing a rotation in “Mental Health”.

I use the term “Mental Health” because, back then, Behavioral Health meant behavior modification using techniques like relaxation exercises, meditation, etc. Mental Health was what we call Behavioral Health today. They changed the name to reduce the stigma of having a Psychiatric or Psychological diagnosis and where you were being seen by your doctor or therapist. I was assigned to the Mental Health Center. The Behavioral Health Department was clear across the campus and was led by an Internist, not a Psychiatrist.

Anyway, I was on call for the night with the Psychiatrist on call. She was a tiny woman, not taller than 5 feet and probably weighing not more than 100 pounds. I was hanging out in the resident’s quarters when I got a page to meet her in the Emergency Department (ED). When I got there, she was seated in the corner behind the nurse’s station holding the ED chart. “This is going to be very interesting for you”, she said.

The patient was a 30-something year old man who was exhibiting very bizarre behavior. He was seeing and hearing things and had unusual body language. He had a history of Bipolar Illness but was on no medications.

We went into the exam room where the nursing staff had admitted him. He was sitting cross-legged on the exam table which was up against the wall. He was a big muscular guy. He was somewhat agitated. He kept flexing his body and his arms. He claimed to hear several voices and saw birds and bats coming out of the corner of the wall near the ceiling. He said he was uncomfortable with this and wanted some help.

The Psychiatrist asked him a series of questions as I just sat there and watched. She then told the patient that she recommended that he be admitted to our Mental Health Inpatient Facility. He agreed to this. We left the room.

The Psychiatrist told me she was fairly certain that the patient was having a Bipolar Psychotic Manic episode and he needed to be admitted and treated as soon as possible. She wanted me to do his admission history and physical (H&P) exam.

We completed the ED paperwork and accompanied the patient, along with a Security Guard, to the Mental Health Inpatient Facility. I went directly to the patient’s room with the patient and a nurse. The nurse was in her late 20’s. The nurse gave the patient a quick review of the room and what was in it and left. I performed the usual medical student comprehensive admission H&P including a very complete Psych review of symptoms and queries. During that time the patient continued with his posturing and flexing, but he was relatively pleasant.

I completed the exam, shook the patient’s hand and excused myself from the room, letting him know that the nurse would be coming in to do her required “intake”.

The Inpatient Unit was an unlocked unit. Dangerous psych patients were not supposed to be admitted there. The on-call Psychiatrist said the patient was somewhat bizarre but she didn’t consider him dangerous. Another thing about the unit was, the place where we all did our charting and had patient care coordination and discharge meetings was right behind the nurse’s station and was enclosed with safety glass with chicken wire running through it. This included the door, which could be locked. We called this the “Charting Room”.

I was in the Charting Room writing up the H&P when I suddenly heard a woman screaming “Open the door!” I looked up and saw the nurse who was assigned to the patient I had just admitted running full tilt towards the door. I opened the door, she ran in screaming, “Close the door and lock it!” I closed the door and switched the lock on it as fast as I could. When I looked up I saw the Bipolar patient also running full tilt at the door! The nurse screamed, “Don’t let him in!!”

Now, I’m standing at the door which is a glass door with my hand held tightly on the door knob to back up the lock. The patient came running at the door, leapt up in the air so his left side was facing the door and hurdled himself into the door as hard as he could. All the while I’m facing the door watching all of this and hoping I don’t get glass and a patient slamming into me!

The patient hit the door and fell to the ground. The glass didn’t even crack! But the man got up and tried to turn the door knob to get in. He tried this for about 15 seconds, then gave up. He then turned to the nurse’s station which had fortunately been vacated by the staff (who had run down the hall opposite the patient’s room and locked themselves in a conference room). The patient then started destroying everything in the immediate area. He banged on the Charting Room windows several times.

As soon as the patient had hit the Charting Room door, the on-call Psychiatrist had called security. Two of them arrived relatively quickly but they were no match for this totally out of control psychotic man. They retreated. The man continued to tear away at the nurse’s station. Interestingly, he didn’t run into the other patient rooms, which all had their doors closed by the staff. He would leap over the counter of the nurses station and bang on the Charting Room windows.

About 15 minutes went by when the two security guards came back with four police officers. They jumped on the man and eventually got him to the floor. The on-call Psychiatrist and the nurse who had run into the Charting Room went out to where the patient was. The Psychiatrist ordered Intramuscular Haldol, large doses. The nurse administered the drug until the man was unconscious. The police officers lifted the man up and carried him out to a police car. They headed down to the State Inpatient Facility about 60 miles away.

The nurse who had run in screaming came back into the Charting Room and thanked me for “saving her”. She said when she went into the patient’s room to do her intake, the patient was crouched on the bed and leapt at her like a tiger. She dropped everything she had in her hands and ran as fast as she could down the hall, hoping someone could hear her screams so she could get herself behind that glass door.

I was so glad that glass door was strong!!

 

 

Babies, Babies, Babies, and Babies

Luckily for most people, having a baby is a happy event without significant complications. However, in my experience, when things in OB go badly, they really go badly.

The following are cases in which I was the Primary Care Physician (PCP) doing OB and in which the cases went very badly. Most had a good outcome despite some scary moments.

When I did OB as a PCP, I was in a 20-bed hospital with no back-up. There were no Anesthesiologists, no Obstetricians, no Pediatricians. I was “it”. Just me and nurses, and at night only one nurse. There were two nurse anesthetists who worked at the nearest big hospital 75 miles away. They worked at our hospital when the itinerant surgeon was in town on Wednesdays and when they were in town they could and would respond to emergencies. They were two of the most dedicated clinicians I ever knew.

If they weren’t in town and you had an emergency, you were SOL for anesthesia services.

As most people probably know, when a baby is born, they are given an APGAR score at one minute after birth. The APGAR score a baby gets determines the level of intervention needed, if any, to treat a newborn and improve their clinical status. An APGAR of > 7 at one minute is considered normal. APGAR scoring has five components 1. Heart rate (over or under 100), 2. Color (pink vs. blue) 3. Reflexes (+/- grimace, cough), 4. Respirations (rate and force) and 5. Muscle tone (limp to active motion).

The following are stories of OB cases when things didn’t go normally.

APGAR Zero

I was in clinic seeing patients one morning when I was called to the hospital to intake of one of my patients who was at term pregnancy. She had had an uneventful pregnancy; her prenatal checkups had been perfect.

Back in the late 1970’s and early 1980’s the birthing room had begun to emerge. Before that mothers-to-be labored in a labor room and were wheeled into a delivery room for the actual delivery. The delivery room looked just like an operating room. The birthing rooms looked more like a home bedroom and the husband and sometimes other family members or significant others were allowed to be present. When I got to my National Health Service Corps site, the little 20 bed hospital had no birthing room. A birthing room was one of the first improvements I championed at the hospital. The mothers-to-be all wanted to have their babies in the birthing room. Of course, they were told their prenatal courses had to be textbook for that.

This mother-to be was no different. She wanted to have her baby in the birthing room. Since there was no contraindication to this, she was admitted there. I did my intake, which was normal, and went back to clinic to see patients.

One thing about our 20-bed hospital was, there was no fetal heart monitor. Fetal heartbeats were monitored by a nurse assigned to that birthing room; caring for the mother-to be was her only duty. She took the fetal heartbeats at predetermined times and during contractions. A paper actually came out in the OB/GYN literature around then that said a nurse with a fetal Doppler taking heartbeats was more accurate than a fetal heart monitor.

The nurse had noted no signs of fetal distress. No heart rate decelerations or low heart rates.

I got a call a few hours later that the mother-to-be was 10 cm dilated and was wanting to push. I left the clinic, ran across to the hospital and ran down to the birthing room.

Now, the birthing room was all the way down the hallway from the labor and delivery room, at least 100 feet. If something went wrong, mother, and perhaps baby, had to be transported down the hall to the delivery room.

I arrived at the birthing room. The baby’s head was crowning. I gloved up while asking the nurse if anything unusual had been observed or had happened. She said no. We had the woman push with her contractions. I ironed the perineum. The baby delivered uneventfully, no prolonged Stage 2 labor and delivery. But, when the baby came out he was limp and not breathing and he had no pulse. I stimulated the baby for about 30 seconds with no response. The baby seemed essentially stillborn! That was an APGAR of zero!

I clamped and cut the cord and told the nurse to deliver the placenta and immediately began CPR (that included mouth to mouth resuscitation) on the newborn while running down the corridor to the delivery room where there was the usual delivery room bassinett which had warming lights, suction, oxygen and other equipment to resuscitate a newborn.

By the time I got to the delivery room the baby had a pulse of about 60 and after suctioning, he began to breath. At about 3 minutes post-delivery the baby finally let out a cry. His APGAR at five minutes was 7.

We watched that baby closely during his two-day hospital stay. His exam, including neurological was normal. I took care of him as one of my patients until I left town two years later. He passed all of his milestones without problems.

I never met another person who had performed mouth to mouth on a baby just out of the birth canal.

APGAR 1

I was on call for the weekend. It was a very, very busy weekend with a busy Saturday morning clinic, steady emergency room activity and several admissions including an elderly septic man requiring continuous attention until he coded and died. I got practically no sleep between Friday morning and about 3:00 in the morning on Monday. I never made it home the entire weekend until then. I got home and jumped into bed at about 3:30 AM. Two hours later, the phone rang. I picked up the phone and heard, “Doctor come in right away, we are going to have a baby right now!….(click}”.

I jumped out of bed and into my clothes (sort of like a firefighter jumping into his gear when the fire bell rings). I bolted down the stairs and out of the house and ran down the street to the hospital. I ran into the labor room and there was a woman lying in the labor room bed with a sheet over her. Out from the right side of the sheet was an umbilical cord which led to a surgical towel on which there was a squirming baby. The nurse was standing to the right saying, “He just came out all on his own!”

The nurse had opened a delivery kit. I quickly gloved up, swaddled the baby, and was clamping and cutting the cord when I noticed that the woman’s abdomen still looked unusually large. I asked the woman, “Are you having twins?” She said, “No!.”

I handed the baby to the nurse and I pulled off the sheet. To my surprise, there were two feet and a prolapsed umbilical cord sticking out of this woman’s vagina. I grabbed a scissors from the delivery kit and said, “Ma’am, you’re having another baby. I’m going to have to cut you and you have to push this baby out immediately!”

I did an episiotomy without prep or anesthesia, had the mother push and gently pulled the baby out. A double footling breech with a prolapsed cord. Ask your OB friends about that.

The baby came out limp with no respirations but a heart rate of about 60. An APGAR of 1. I clamped and cut the cord and ran into the delivery room with the baby while stimulating the baby’s feet. I got him into the delivery room bassinette and suctioned and stimulated him. He started to breath and then cry and then move all extremities. His APGAR at five minutes was 9.

I turned the care of the babies over to the nurse and stitched up the episiotomy. Then we handed the babies to the mother after the second baby was stable and asked her why she didn’t know she was having twins. She said she only had one prenatal visit at 12 weeks of her pregnancy with a doctor in a town about 40 miles away. She didn’t have insurance and couldn’t afford the prenatal care. I guess no one there talked to her about getting on Medicaid.

The second twin did well in the hospital, despite the difficult delivery. I saw her for her six-week post-natal care and also did the well-baby checks. She established with another primary care physician 40 miles away.

Prolapsed cord

It was about noon on a weekday. I don’t remember which day of the week. I was on my way to lunch at the hospital when the nurse came up to me and said she just admitted one of my mothers-to-be and I had to go see her immediately. She was in the labor room.

I hurried over to the labor room. I was saying hello to the woman when the nurse said emphatically, “Examine her first!”. I gloved and pulled the sheet down and did a vaginal exam (which the nurse had done, obviously) and felt a 9 cm dilated cervix with a prolapsed umbilical cord.

Yikes!! This is an OB emergency! If we were in a larger hospital, this woman would have been rushed off to the OR and had a C-section.

Since we had no OB back up and no Anesthesia Services, we normally would have had to ambulance this woman to the nearest big hospital 75 miles away. This woman was going to deliver by the time we got there and the baby would be dead by then since the cord was being compressed by his head.

Suddenly I remembered that the 20-bed community hospital 30 miles north of us had just hired a Family Practitioner who had spent a year following a surgeon and OB/GYN around to get proficient with appendectomies, gall bladder surgeries and C-sections. I called that hospital, quickly explained the situation and they said, “Bring her on up!” The volunteer ambulance crew was summoned.

I ran to the labor room, gloved and pushed the baby’s head up off of the cervix until the ambulance was ready to transport the laboring woman. We ran to the ambulance and sped off to the nearby hospital. During the ride up there, I intermittently pushed the baby’s head up off the cervix. The mother was now at ten cm and wanting to push. The EMT and I coached the woman on breathing through contractions and avoiding pushing.

We got to the hospital and the ambulance backed into the ER ambulance entrance. The back door of the ambulance opened, and the following scene was like something out of Ben Casey (anyone remember that TV show?).

There were six or seven people in scrubs waiting for us. We got the woman on the stretcher out of the ambulance and four people, myself and an EMT began running across the asphalt, through the doors and down the hall pushing the stretcher. While we were running, one of the hospital staff pulled the sheet off of the woman and started splashing betadine on her abdomen. We crashed through the OR doors where two Family Practitioners were already gowned and gloved and the OR staff stood ready. One Family Practitioner quickly started intubating the woman while the nurse anesthetist started giving anesthesia while the second Family Practitioner started a vertical incision of the abdomen. They called it a “crash induction”. Myself and the two EMT’s who came with me stood at the doors of the OR as the two FPs performed a rapid C-section, getting that baby out in less than five minutes. Wow!

The baby cried immediately and had APGARs of 9 at one minute. The FPs closed the uterus and abdomen in normal fashion.

We thanked the staff and doctors profusely. The mother and baby did just fine. I followed the baby until I left there and there were no health issues relate to this complicated birth.

Sisters-in law

This is a double story about two women who were sisters-in law (wives of two brothers) and their pregnancies. The names in this story have been changed from their real names. I’ll call them Jane and Mary.

Jane had come in for a first prenatal visit at about week 12 of her pregnancy in late February. We calculated her delivery date and it was December 25, Christmas! From then on we both called her baby the Christmas baby.

About two months later, her sister-in law, Mary, came in for her first prenatal visit. According to her information, her delivery date was in February.

So, now we had the two sisters-in law having babies within two months on each other. This created a lot of happiness and joy in that family and the sisters-in-law shared the journey of their pregnancies.

Now, back then, the ultrasound (U/S) technology was still somewhat rudimentary. Two-dimensional U/S was just emerging. Our Radiology department had purchased a used first generation 2-D U/S machine (already obsolete when the hospital bought it). The images were somewhat “muddy” but that’s all we had. The newer ones weren’t much better back then. We did OB U/S three times during pregnancies. Both of these women had normal U/S tests.

I saw Jane in clinic the week before Christmas. Her exam was normal, the baby had normal heart rate. Jane said the baby was very active. On exam the baby hadn’t “dropped” yet (when the baby’s head enters the pelvic canal getting ready for birth).

It was December 24^th. I was still in morning clinic when the nurse called and told me Jane had come in in active labor. She asked that I come right over to see Jane.

You’ve probably figured out that nurses saying get over there right away wasn’t a good sign…

I excused myself from clinic and hurried over to the hospital. The nurse met me at the door to the labor and delivery suite. Jane wanted to be in the birthing room. I asked the nurse what was going on. She said, “I can’t find a fetal heartbeat. Could you check her?”

I went into the labor room as if nothing was going on. I did a normal OB intake, asking about what her week was like. She said the baby stopped moving two days ago, she thought it was normal as the baby was getting ready for delivery, so, she didn’t call us to tell us.

As was usual for my intake process, I did my own fetal Doppler. I couldn’t get a fetal heartbeat. I told Jane that we were going to get an U/S to check on the baby. She was wheeled down to radiology and back to the labor room. I reviewed the U/S with the U/S tech. There was a term fetus with no heartbeat. The baby had died, likely two days before.

Now I had to go back to the Labor Room and tell Jane. It was one of the hardest things I ever did as a physician. She cried. I had to be stoic and hold in the tears myself. Unless you’ve been an OB or Midwife, you wouldn’t understand the bond between the patient and the OB/midwife. I had to also tell her that we had to deliver this baby as soon as possible. We had no way to do a C-section. Jane had to deliver a known stillborn on Christmas eve.

I left the labor room. The nurse was right outside the door. We both cried. I had to go back to clinic and see the rest of my afternoon patients. It was hard to do that.\

I got out of clinic. Jane had progressed well and was almost at transition. We wheeled her into the delivery room. She reached transition and began pushing with every contraction but the baby wasn’t coming out. She was starting to become exhausted. I had to get that baby out.

I went over to the instrument cabinet. I looked through the glass doors and found delivery forceps. I had never used them. I had only read about how to use them. I knew I had to use them now.

I pulled out the forceps. Walked over to Jane and told her what I was going to have to do and it might be painful. She nodded.

I went back to the foot of the delivery table and inserted the forceps just as Jane was having her next contraction. I yelled for her to push and I manipulated the forceps as I had read (you don’t pull on them). I got the baby’s head out and it was apparent what had happened. He had a triple wrapped umbilical cord around his neck. There wasn’t enough length in the cord for him to come out. When the baby dropped several days before, he was essentially strangled. I had to cut the cord from his neck to further extract the baby from the birth canal.

The baby was perfect in every way. It was very sad.

Jane had an uneventful two days in the hospital after delivery physically. Emotionally, was another story. She went home with an appointment to see me in a week.

Jane came in for her one-week check with her husband. I entered the room, said “Hi” to Jane who was sitting on the exam table and touched her left arm. I went over to her husband shook his hand and said how sorry I was.

Then Jane said, “Doctor, come here.” I turned and went over to Jane. She held out her arms and gave me a big hug. “They told me how this was as hard for you as it was for us.” I glanced over to her husband who nodded. It was a pretty powerful moment.

But, the story doesn’t end there.

Remember Mary, Jane’s sister-in-law?

Mary also had a normal prenatal course and three normal OB U/S’s. She came into the hospital in labor the next February. Her baby was still active. The baby had normal fetal heart sounds and rate on intake exam. Everything seemed normal. Mary breathed a sigh of relief.

Mary had chosen to be in the Labor Room, I think because of Jane’s story. Her labor went uneventfully. She reached transition and was transferred to the delivery room. It turns out, her choice was a good one.

Mary’s delivery actually went according to the textbooks. However, when the baby was birthed, there was a shocking discovery. The left side of the baby’s face was malformed. He was active and crying with an APGAR of 10.

Instead of immediately showing the baby to Mary, I handed the baby to the nurse and told Mary that we had to examine the baby. I told her there was a problem. “What is it?”, Mary asked. I told her it looked like there was a congenital defect that I would explain to her after the baby was examined.

While the nurse was cleaning the baby in the bassinet so we could get a good look at what the issue was, I was waiting for the placenta to deliver. All of a sudden, there was a waterfall of blood coming out of Mary’s vagina. I tried to tug on the cord to remove the placenta so I could give Mary some methergine (that’s what we used back then to contract the uterus to stop or prevent bleeding) and massage the uterus to stimulate the uterus contracting, but I couldn’t get the placenta out. It was a trapped placenta! The cervix had contracted before the placenta had come out. With this degree of bleeding, this is an OB emergency! If you couldn’t get the  placenta out right away, the mother would bleed to death! The only way to get it out was, you had to anesthetize the mother which allows the cervix to relax and release the placenta, then you inject the woman with methergine and aggressively massage the uterus to stop the bleeding.

That meant we needed an anesthetist. Remember, the nurse anesthetists (NA) were only available if they were in town and not up at the big hospital. I barked for someone to call the NA. I placed two large bore IV’s into both the patient’s arms and ran IV Normal Saline full bore. We wheeled the woman into the OR. The Nurse Aid came in saying the NA was on her way.

Five minutes later, the NA ran in. She Induced the patient as fast as possible, while blood was still pouring out of the patient. Once the patient was fully under I tugged on the cord again. After a few tugs, the placenta delivered. I barked the order to give the methergine and began vigorously massaging the uterus. The uterus shrank quickly and the bleeding stopped. The patient became stable with a normal blood pressure but was tachycardic. After several liters of IV fluid, her vital signs were normal. Her blood counts showed she had bled about four units of blood. We gave her two units of blood. She did well post-partum.

Her baby had a branchial cleft deformity, not picked up on U/S. He had some of his left jaw missing and only a partial ear and no ear canal on the left. Otherwise he was normal and had a normal newborn stay in the hospital.

I referred Mary and her baby to a tertiary care center where he was evaluated by a group of specialists. The baby’s care plan was a series of reconstructive surgeries that would take at least 16 years, in phases as he grew. Luckily, all of the stars aligned the day of his birth and we were able to save the life of his mother.

It was one of the scariest medical events I ever expe

Insulin, anyone?

It was 1991. I was on call and on Service Call at the hospital. It was early evening when I got a call from the Emergency Department (ED) that there was a patient needing admission to the ICU and I was next up on the call list for admitting patients without a primary care physician who admitted to the hospital.

I jumped into my car and whizzed down the highway to the hospital. ICU admissions always required promptly arriving at the hospital. After parking in the physician’s parking lot I ran into the ED. I checked in at the nurse’s desk and they pointed to an ED bay that was crowded with various caregivers, from ambulance crew to nurses to respiratory therapists to physicians. I ran over, introduced myself and announced that I would be the admitting physician and wanted a summary of the case. Here’s what I was told.

The patient was found seizing in the street. Bystanders called 911 and an ambulance was dispatched to the scene. They found an approximately 30 year-old woman having serial seizures. They medicated her with valium and transported her to the hospital. The ED team was having a hard time stopping her seizures. Her initial work-up revealed an extremely low blood glucose, below 30. As most people know, very low blood glucose levels (severe hypoglycemia) cause seizures. They had given her several doses of D 50 (a 50% solution of glucose) and they were still having trouble getting that glucose level higher. Because of the low blood glucoses and difficulty controlling the seizures, the ED physician placed a central IV line. As I recollect, it was a subclavian central IV line.

We brought the patient up to the ICU and over the next 12 hours got her stabilized and seizure free by infusing glucose and antiseizure medications. The hospital administrative staff, having gone through her wallet, had found out her name and the local police department did a search for her family. It turned out, this patient was actually from Toronto, Canada (we were in a Canada border state) and had a very interesting history. The patient had a trail of hospital admissions from Canada into the U.S. which were very suspicious. We called the last hospital she was in and the story they gave us was that the patient was doing “things” to herself to get herself admitted to the hospital. Injecting herself with insulin and causing seizures was one way she had gained admissions to hospitals. As I recollect, she also injected herself with feces to start a bacterial infection at least once. Once admitted, she was a problem patient, causing disruption, etc. She usually signed out against medical advice (AMA) when she decided it was time to “move on”.

Now, back then and even today in most states, older insulins (like pork regular insulin) is actually over the counter and so are insulin syringes. Our patient would go to a pharmacy, say she was a diabetic who was out of insulin, get insulin and syringes and then inject herself with large doses of insulin. She was not diabetic. We were the fifth U.S. hospital she had been in that year.

We confronted her with this information and had an endocrinologist and psychiatrist consult ordered. During the next day, she again had an episode of very low blood glucose requiring intervention. I was suspicious that she had a supply of insulin hidden somewhere in her room. None of the admitting or floor nursing staff had looked through her purse. I went into her room, grabbed her purse and found several vials of insulin and a fistful of insulin syringes. This infuriated the patient who proclaimed she was going to sign out AMA.

At that point, this was actually not risky for the patient as her only finding from two days of testing was she was giving herself insulin. She had no other significant medical problems. The issue was, she still had that central IV line in, giving her an easy, direct access to her blood stream. I told her we would have her sign AMA papers (this absolves the hospital, the staff and myself from a lawsuit if the patient deteriorated after leaving the hospital), but, we had to remove the central IV line.

The patient refused to let us remove it.

Of course, we didn’t want to let her leave with a direct central circulation access with her history of her injecting herself! We tried to approach her to take it out and she would grab the bed covers and assume a fetal position, protecting the central line entrance site. The only way we could get that line out would be to have a half dozen nursing staff and security staff descend on the patient and wrestle her into four point restraints.

It was about 10:00 at night when the patient was yelling that she wanted to leave the hospital and started creating a big fuss in the ICU. Not wanting to just let her go with that central line, I asked to have the hospital’s legal counsel summoned to get an understanding of what we could do to get that line out before the patient left (at this point, the staff was more than ready to get her out the door).

The hospital lawyer and I talked over the phone and she said she would come in. Twenty minutes later the lawyer arrived and she went in and interviewed the patient and reviewed her history of abusing herself. After that she came over and said 1) We had to let the patient leave AMA if she wanted to, and 2) If she wanted to leave with the central line in, we had to let her do that. We couldn’t wrestle her into submission and remove it as that would be assault and battery and not only could whoever participated in getting the line out  be arrested, the patient could sue the hospital and all of us for attacking her! Of course we were all flabbergasted!

The lawyer helped us amend the AMA papers to include language specifically calling out the risks of leaving with the central line including a paragraph referring to her previous risky behavior.

The patient gleefully signed all of the papers and a nurse and security officer wheeled her to the exit of the hospital where the patient got into a taxi cab and disappeared into the night.

We never saw or heard from her again. I was thinking, she would be lucky to live another year, all because of the legal ramifications of this case; our being unable to force a person like that to have a central line removed, which was a mode of therapy applied by the hospital staff to help treat her, and which she would likely lethally abuse.

You can bet I factored that case into my future decisions regarding placing central IV lines……

She didn’t have the right doctor

It was December 21^st, a Thursday. I was in clinic seeing same day acute care patients, which was kind of a low key urgent care function in a Primary Care clinic. I essentially saw people who called in to see their Primary Care Provider (PCP) but the PCP couldn’t (or wouldn’t) see them. It was about 3:00 PM. I picked up the next patient’s paper chart from the bin outside the exam room and entered the exam room.

There were three people in the room: a really elderly woman (she ended up being 92) who was the patient and was sitting on the exam table, an elderly man (he looked to be mid to late 70’s) and an elderly woman who was severely hunched over clutching a cane. The patient was the hunched woman’s mother who lived with her and her husband. The husband referred to the patient as Mrs. Olsen (not Mom or mother).

I introduced myself to the three of them. I asked the patient what occurred to have her come into the clinic that day. She said she felt tired and a little short of breath. The man said she had been feeling and looking worse for several days. He also pointed out that the patient had developed swelling in her feet and ankles.

I asked about the patients past medical history, her medications and a review of systems. I then examined her. She had jugular venous distention, an irregularly irregular heartbeat at 120, crackles in her lungs half way up and pitting edema in her feet and ankles. She was clearly in congestive heart failure (CHF) most likely due to her irregular heart rhythm. I did an ECG. She was in A-fib with a rapid response rate. I had the nurse draw a CMP and thyroid function tests. Being 92 and the degree of heart failure, I believed she needed to be in the hospital for a work-up (like, echocardiogram) and treatment for the A-fib and CHF.

I advised the patient and her family that I thought she should be in the hospital for a couple of days to improve and stabilize her condition. The patient didn’t want to go into the hospital. She was fairly adamant about this. Her son-in-law tried to convince her. I stepped out of the exam room and asked my nurse to contact our main hospital to get an inpatient bed. I also had a full schedule of patients to see every 15 minutes. I saw a patient then went back to the 92 year old patient’s room. The first three times I did that, she was still not wanting to go to the hospital. The fourth time, she said yes!

In the meantime, my nurse had contacted the hospital and was told the ER and hospital were on divert, a Code Black! They suggested we contact the out-of-network (for this patient’s insurance) hospital in our city, so, the nurse called there and, of course, they were happy to take her. I was working in a capitated medical group at the time and this would mean a huge medical bill for the group. The cost of out-of-network hospitalizations was clearly communicated to us by the administration.

I thought I had a successful brainstorm when I thought of a secondary in-network hospital with a 30 bed medical unit. The patient didn’t need an ICU, so that would work! I personally called the hospital and got transferred to the medical unit. The nurse manager said they had a bed and could easily take care of the patient but, she didn’t have the nursing staff to cover the empty beds they had. They were short staffed!! She declined accepting the patient!

I then remembered that the medical group had just started a cardiology clinic in the same building as our clinic. I asked the nurse to see if I could talk to a cardiologist. Since the clinic was new, they weren’t very busy and I was pleased when a cardiologist actually showed up, in person, at our clinic pod. We went over the ECG, the patients history and meds and her physical findings. The cardiologist turned to me and said, “You know, we could probably treat her as an outpatient.” It wasn’t the best solution, but, trying to balance the patient’s wishes (she really didn’t want to go to the hospital), the odds of success of and outpatient treatment plan and the cost of the out-of-network admission, we decided to try the outpatient approach. The cardiologist outlined the care plan. I was a little nervous about it, but I decided to try it.

I went back into the patient’s room and had to tell them that I couldn’t get her into the hospital because of the Code Black and lack of staffing, but that I had consulted with an on-site cardiologist who had given me an outpatient care plan; were they OK with that? The patient was very happy about it. The daughter and her husband said they were willing to try it.

I wrote out instructions and prescriptions. The one thing that worried me was, it was a three-day Christmas weekend and I couldn’t get her re-checked for four days, the current day being a Thursday. The patient and her family left and I finished clinic.

The next day I was back at my physician executive job in an office at the health system’s main offices. I couldn’t get that 92-year-old patient out of my thinking. At noon I called the pod clerk at the clinic and asked her if she could give me the patient’s telephone number so I could call and see how she was doing. I got the number and called. The son-in-law answered. I asked how Mrs Olsen was doing; he said she seemed OK. Had they gotten her medications? Yes. Had she taken them? Yes. Was she having any trouble with the medications? No. I then told him I would like to come to their home the next day (Saturday) and check on his mother-in-law. He said, “Really, you would do that?” I said, “Of course, she could have been in the hospital. Some medical provider should check on her.” He said that would be great. I asked for their address. He told me their address. I was floored! They lived one block away from me! This would be the easiest house call I ever did! I told him I would be there at about 10:00 the next morning.

I walked over to their house the next morning. The son-in-law let me in and ushered me into kitchen. He called down the hall for his mother-in-law. She didn’t come out. He called for her again saying, “Mrs. Olsen, your doctor is here!” We waited again and about five minute later she came wheeling down the hall in a wheelchair.

I examined her. Her heart was in normal sinus rhythm. Her lungs had only crackles at the bases. There was only about half the swelling in her feet. She was doing a lot better. I told her she was doing fine and left. I went back the next day and she was doing even better. She was out of the woods for that episode. I had booked her an appointment with her PCP for December 26^th, so, I was sure she would do OK. That’s the last time I saw her.

About two years later, my wife was walking our dog one morning when she ran into Mrs. Olsen’s son-in-law in his driveway. She asked how Mrs. Olsen was doing. Sadly, he said she had passed away about six months earlier. He told my wife he had to tell her a story that he told at her memorial service.

It turned out that Mrs. Olsen was on the telephone with a friend in the state capital 60 miles away when I visited her on that Saturday. When her son-in-law called down that her doctor was there, she said to her friend, “Alice, I have to go, my doctor is here.” The friend said. “What, you have to go see a doctor?” Mrs. Olsen said, “No, my doctor is HERE! In my house. He came to check on me.” The friend said, “What?!? I’ve had the same doctor for over 30 years and he’s never come to see me in my house!” Mrs. Olsen said, “You haven’t got the right doctor!”

Eighteen months later, Mrs. Olsen fell and broke her hip (or her hip broke and she fell to the floor). The ambulance was called and she was transported to the Emergency Department of the main hospital. They put her in a room, put in an IV and took her vital signs. They sat there for hours without anyone coming back into the room. After about six hours, Mrs. Olsen looked over at her son-in-law and said, “I don’t think we have the right doctor!”

Unfortunately, Mrs. Olsen never made it out of that hospital alive. I wish I had known she was in there, I would have visited her. She was quite the character!

Oops! Poops!

The following are two stories with the same response tactic. Both patients were suffering from dementia.

The Elf Man

It was 1981. I was a second-year resident in training. About a third of our training time was based out of a VA Hospital. At the time, if you were a veteran, you weren’t turned away. We were in Vermont, which is a predominantly rural state. There were always veterans that came out of the forests with non-traditional living experiences. Some people would call then hermits living in squalid conditions. With one such fellow, we had to bath him four times until he didn’t smell bad before the staff would do an intake. Often, they were “rescued” from themselves by government authorities.

This is the story of an elderly man who ended up getting the nickname of “The Elf Man” or “The Elf” for short. He was “rescued” from the woods by the state police based on a citizen complaint, and, since he was a veteran, they brought him directly to the VA. He was diagnosed with dementia. He was non-verbal, but he seemed to know what he was doing. He didn’t have any serious medical problems and after about a week, he was considered a “social admission”. The staff let him wander about the Medical Service floor without much supervision. He was pretty calm, but somewhat mischievous. For example, he would crawl in bed with other patients in the middle of the night. Once he was found asleep in a vacant ICU bed. He, sort of, became the floor’s mascot! He was there for months.

In training programs, third and fourth year medical students rotate through the various services similar to the interns and residents. At the time of this story, we had four medical students, one of which was a somewhat stern young woman. I’ll call her Jane. She had little patience for the Elf man, considering him a nuisance.

Typically, when admissions occurred, medical students would either choose or be assigned a patient, and they would usually do an admission history and physical (H&P) first, so they wouldn’t be influenced by the intern or resident’s admission H&P. The student was supposed to try to accurately make a list of the patient’s problems and describe how they were going to confirm diagnoses and treat known conditions.

Jane was assigned a newly admitted patient and dutifully went into the patient’s room to do her admission H&P. At that time at this VA, these rooms were mostly “quad” rooms, meaning, there were four patients to a room separated only by curtains you pulled around the beds for some degree of privacy. Jane pulled the patient’s curtain and began taking a history when the Elf snuck in and stood watching what Jane was doing. Jane shooed the Elf out and continued. The Elf snuck back in and began watching again.

This infuriated Jane. She began yelling at the Elf and pulled him by the arm, marching him out of the room and ordering a nurse to “take care of him”. Then Jane went back to doing her admission H&P. After completing the history and review of systems, Jane put her “doctor’s bag” with her physical exam equipment on the chair next to the bed that visitors used. It was near the foot of the bed. She opened the bag and was in the middle of examining the patient when she heard a rustle. She turned around and saw the Elf standing next to the chair with a wry smile on his face. Jane started to yell at the Elf when he pulled up his hand in which there was a well-formed stool which he rapidly proceeded to throw into Jane’s doctor’s bag, soiling all of her equipment! Then he bolted out of the room. Of course, it was his own stool, he had pooped into his hand!

Of course, Jane became hysterical. A huge commotion resulted. The Elf was transferred to a long-term care facility within a week.

The Man With The Cane

It was 1984. I was in the National Health Service Corps. At the time, I was the Medical Director of the Nursing Home and 2/3 of the residents there were mine, about 50 of them. The remainder were followed by their respective PCPs. When you were on call for the hospital, you were on call for the Nursing Home.

One night when I was on call, I got a call from the Nursing Home at about midnight. The charge nurse called and said a demented elderly resident had come out of his room armed with his cane, swinging it at the staff and was now at the end of the hall slamming the cane into the door that was the exit. The staff was afraid he would escape, and they said they couldn’t de-escalate the situation and weren’t able to get the cane away from him.

I immediately got dressed and walked down to the Nursing Home, 1.5 blocks from my home. I walked past the nurses’ station and there at the end of the hall was this scrawny elderly man who couldn’t have weighed more than 100 pounds in a baseball player hitting stance standing by the safety glass and chicken wire exit door which had several smashed areas where the man had struck it with the cane. Keeping a safe distance was 5-6 nurses and nurse aides who were trying to talk the man into putting the cane down. When they saw me, they all (at once) started telling me about his belligerent and violent behavior.

I looked at the man and then the nurses and said, “I can get that cane in less than one minute.” It seemed to me that he was so debilitated that he couldn’t possibly swing that cane with any significant force that I couldn’t handle.

I walked up to the man to within the length of his cane and urged him to swing it at me, which he did. As the cane came around at me I easily grabbed it out of his hand. Instantly there were five nurses on him. They ushered him down to his room which was about 20 feet away, all the while the man was fighting to get loose. I followed the nurses into the resident’s room. The nurses plopped him onto his bed and I walked up next to the bed by the resident’s head. All of a sudden, the man became completely calm. There was a communal sigh of relief by the staff. They started tucking him in when all of a sudden, I saw his hand come up from under the covers. It held a formed stool! He had pooped into his hand!

I yelled for the nurses to watch out as I pulled the bedside curtain toward the foot of the bed creating a barrier between me and any nurse standing next to me and that stool. Everyone hit the deck! The man threw the poop at the nurses at the foot of the bed. Luckily, they had ducked behind the foot board!

Pandemonium ensued! I was laughing my butt off!

The nurses restrained the man’s arms. He finally calmed down; I think he just ran out of energy. We didn’t medicate him. It never happened again.

Well, this story is not about patients. It’s about hospitals’ control over doctor efforts coupled with doctors’ ignorance about legal and business issues. Unfortunately for hospital systems, I wasn’t one of the ignorant ones.

I moved to a new city in a new state. When a doctor does that there are a lot of things that have to be done to actually begin to see patients. Back in those days (1990) that included getting privileges at at least one hospital. In order to get privileges, you have to file an application with the hospital to become one of the hospital’s Medical Staff. Initially the Medical Staff was exclusively doctors, but nowadays, that includes other licensed caregivers like Nurse Practitioners, Physician Assistants, Podiatrists, etc.

As the process went, you had to be licensed in the state, have medical malpractice insurance and have a valid place of practice. I had a license. I was employed by a large multispecialty group which supplied me with malpractice insurance. Since I would be on call as well, I had to live within 30 minutes of the hospitals in the hospital system. You had to fill out the application and request the types of things you wanted to do in the hospital. I’d done this several times before with several different hospitals with no problems.

At this new hospital system, there was, to me, a surprising last paragraph just above where you sign the application. Signing the application was the same as signing a contract. The paragraph said something similar to this: “If there was an adverse action taken by the hospital Medical Staff review process and the undersigned experienced an adverse decision, like being expelled from the Medical Staff, the undersigned will consider the Medical Staff decision as final and cannot seek deliberation in a court of law or any other legal venue.”

Now, for those of you who are knowledgeable in legal issues, this is called “signing away your rights”. Essentially, that paragraph was barring you from suing for an action that could put you out of business, since, back then, you really had to have hospital privileges to cover your panel of patients. That paragraph put you exclusively at the mercy of the hospital and its Medical Staff which could be significantly biased. There are many instances where hospital Medical Staffs have discriminated against doctors, sometimes for financial/competition reasons and sometimes for ideology reasons. For example, a hospital Medical Staff once refused to review applications for admission to the Medical Staff of physicians who were working for a staff model HMO, calling the HMO “pinko-communist”. The HMO doctors had to go to court to get hospital privileges. Do any of you think the “conservative” Medical Staff leaders might be headhunting the HMO doctors once they got privileges? There was also a case in Oregon where the surgeons on the hospital Medical Staff tried to force a new young surgeon off of the Medical Staff, leaving a paper trail in their committee minutes. The new surgeon won the court case. And if you were the new kid on the block, well, just think about that.

Soooo, I crossed that paragraph out and made a note in the margin saying I agreed with everything in the application except this last paragraph and by crossing it out I was not agreeing to its content.

About a week later I got a call from the hospital Medical Director asking me to fill out a new application and not cross out the final paragraph, as it was rejected by administrators of the credentials committee for not being “clean”. I told him I wouldn’t fill out a new one, and if I did, I would do the same thing again, and that they couldn’t legally make me agree to the content of that paragraph. I told him why and he said, “Well, all the other doctors have signed it.” I said I wouldn’t because I would be signing away my rights. He said he would take my application to the Credentials Committee for consideration. 

About a month later I got a call from the Medical Staff Office administrator telling me the application was declined and I had to fill out a new one without crossing out the last paragraph. I said I wouldn’t do that, and if the hospital and its Medical Staff didn’t approve my application, I would have to take legal action. Two days later, the hospital lawyer called me while I was seeing patients. He told me that the hospital’s position was that all applicants had to sign the application with that final paragraph intact. I told him that the paragraph was signing away my rights and that I knew that no one can make me sign away my rights, it has to be voluntary. The fact that they were essentially holding me hostage by not approving my privileges for the only reason that I wouldn’t sign away my rights was illegal. He said, “But all the other doctors signed it for years and years”. I said, “Well, all of the other doctors are apparently ignorant and maybe even stupid. Unfortunately for you, I’m neither ignorant nor stupid.” At this point the lawyer went on a rant for about five minutes, calling me names, accusing me of all sorts of things, etc. When he finally stopped, I simply said, “I have to see my patients. You’ll be hearing from my lawyer about how you are restricting my ability to have a livelihood.” And I hung up.

Now it was time to actually do more than just talking. I researched which law firm in the city was the most intimidating. On the line was at least 25 years of me being able to practice. Assuming a salary of $150,000 for 25 years, the minimum I should sue for was 25 x $150,000 = $3,750,000. I was thinking $5,000,000 was a nice round number to go for. I found a high-powered law firm that was the only firm in the city that sued other lawyers for malpractice. I thought, “These guys must have balls!”, so I called them and described my situation. I could hear them drooling over the phone. They gave me an appointment right away. I went in and met with a lawyer who told me I had an excellent case. I had to pay him $750 for the consult, but it was worth it.

Now, during all of this, the Medical Director and Administrator of the medical group I was in kept asking me what was going on, so I had kept them up to speed. When I told them that I had hired the high powered law firm, they were taken aback. At the same time, I contacted the Medical Staff Affairs Office and told them they would be hearing from my lawyer from that high-powered law firm. I was trying to throw the name of that law firm around as much as possible. They had a reputation in the city.

Boy, did the wheels start moving after that! Within a week I was asked to meet with my Medical Group leaders at a conference room at the hospital at 6:30 AM. They had been immediately called by the hospital after my call to the Medical Staff Office. They had had an emergency meeting with the hospital administrators and their lawyers. They wanted to settle the issue ASAP without going to court. The deal was, I would sign a “clean” application but with a letter attached saying I did not agree to the last paragraph and if I felt I was being unfairly treated by the Medical Staff and Hospital, I retained my right to go to a court of law. The letter would be signed by myself and the hospital Medical Director. I told my group’s leaders that I would agree to that, but, I wanted one more thing…that the hospital had to pay my $750 legal bill because I never should have had to go to a law firm to retain something that was mine under the US Constitution (Seventh Amendment). My lawyer’s bill was paid. I’m not sure if the hospital paid it or the Medical Group, but it wasn’t me.So, the moral of the story is, never sign away your rights. No one can make you do that. Read the fine print because lots of people and corporations try to make you do t

I was a third-year medical student in 1978 doing the Neonatal Intensive Care Unit (NICU). Where I went to medical school was very rural and we had a NICU outreach program for the smaller hospitals in the region that couldn’t adequately take care of premature infants. Depending on the gestational age of the infant and the clinical status, either an aircraft would go or an ambulance.

One afternoon, a hospital called for a transfer of a premature infant. The baby was several weeks premature, not a critically premature baby, but the referring hospital was not comfortable keeping the baby there. The referring hospital was about 2 hours from our facility. The decision was made to send a team with an incubator by ambulance. As the medical student, they thought it would be a good experience for me to go along.

We got on the road and got to the referring hospital at about four o’clock in the afternoon. The team assessed the baby, took over the case, settled the baby into the travel incubator, loaded the baby into the ambulance and started back to the medical school hospital. It was about 6:00 PM.

About 15 minutes into the ride back, we passed through an area with multiple fast-food restaurants. The resident in charge asked the intern and nurse what they thought about stopping at McDonald’s for burgers and fries. The intern and nurse said the baby was stable and it should be OK to stop for the 10 minutes or so it would take to get something to eat.

The resident, intern and I got out of the ambulance and went into the McDonald’s. It was busy because it was dinnertime. While we were waiting in line, the grandparents (who we had all met) walked into the McDonald’s and spotted us! They immediately came up to us and angrily asked the resident and intern what the heck was going on. The resident tried to reassure the grandparents that the baby was stable and was in no danger, but that didn’t assuage the grandparents.

We left and continued our ride back to the medical school hospital. By the time we got back, the grandparents had already called and complained to the hospital leadership. The resident and intern were called into the Chief of Pediatrics office the next morning. I wasn’t there, being the medical student and having no accountability. Needless to say, no one stopped on the way back from a baby pickup after that!