A Feather in Your Cap

On overnight shifts, nursing homes are the bane of my existence. If you have been reading for a while, you probably have noticed that I actually tend to favor geriatric patients, particularly those with dementia. The problem with nursing home patients on an overnight is that we are on a strict time limit. In this city, while there are plenty of ambulance services to get patients to the hospital, once a bed-bound or even wheelchair dependent person gets here, if we are ready to send them home, there are no transport services available between the hours of 10 pm and 8 am.

This is appalling.

What it boils down to, is that if I can't get my geriatric patients dispositioned by about 9:30 pm, then they are stuck in the Emergency Department until the next morning as "Overnight Guests". Imagine being 80 years hold with dementia and being stuck on a plastic lined mattress for over 12 hours, with all sorts of screaming, bright lights, and not to mention bad smells surrounding you. A sleepless night certainly isn't going to help any, as a lot of dementia patients tend to decompensate at night. Sure, there's a call bell at their bedside, but for someone who can't remember their address or thinks that Harry Truman is the president, how do you expect them to remember to call for help? It's difficult on our staff too, to have to go in and reassure these patients every 15 minutes when they cry out for help.

So, when I see a nursing home patient in the rack on a night shift, there's always a ticking sound going off in my head to get the labs done, and get the x-rays back in time to arrange for a ride. On overnight shifts, the deadline has already passed, so any patients that come in are guaranteed to be stuck until morning. We have tried all sorts of creative options ranging from calling local family members for transportation to taxi cabs, if the patient is able to be transported sitting up and can fit in the backseat of a regular vehicle.

Unfortunately, some of the staff members at these facilities seem to be aware of our transportation problems and take advantage. If grandpa or grandma is being particularly cantankerous, one phone call gets them transported to the ED for "changes in mental status" and gets them off the hands of the night staff, sometimes even for a day or two. While some of these assisted living places are great about sending paperwork, too many times I walk into a room and meet a senior who not only can't tell me if anything hurts, they can't tell me anything about why they are in the department. This leads to what we call the Granny Grope-o-Gram, a workup including lots of tests that are probably unnecessary, but rule out major bad things... head bleeds, hip fractures, pneumonia, etc.

The other night, I walked into Room 4 to find a nursing home patient who was sent in for "purple, pulseless feet." She was very with it mentally, but when I asked her why she was there, she said, "Frankly, my dear, I haven't the foggiest idea." I examined her feet: they were not swollen, and were warm and pink. She had great pulses. Nothing hurt. After calling three different numbers and paging the provided "staff nurse" someone finally returned my page 3 hours later, to verify that my patient had just been sent for a foot evaluation. By this time, it was 4 am. So, I tucked my friend in, ordered her a breakfast tray, and sent her home in the morning.

The other night, I was amused to see a complaint of a rattlesnake bite listed on the board. There are no rattlesnakes here, and it is winter, so there should not be anyone getting bitten by anything other than a pet snake. As it turned out, the patient was from a nursing home. He was a creative guy, and had an old Stetson hat that he had decorated with several feathers and the head of a rattlesnake. This thing was at least 10 years old, but apparently during the day, he had scraped his finger on one of the fangs of the snake. No way he had been envenomated, but the facility had sent him in for evaluation after-hours. So he was an overnight guest too.

I guess these sort of transport issues are why some departments have opened observation units for people who don't have any active issues going on, but either they can't be set home (too intoxicated, no available psych beds, etc.) either. It's easy to see how having 3 or 4 patients stuck in rooms indefinitely causes waiting room overload, and eventual department closure to ambulances as we have no space for more patients. It's a frustrating thing. Hopefully, someone will eventually start up a transport service in the near future, but until then I don't know how to fix it.