[A rerun, first posted 03/01/2010. Things have improved with the Home First program. I am returning tomorrow.]
It’s been my firm belief in life that picking up the phone is always trouble.
I’m lurking innocently the other day around the ward clerk’s desk when the phone rings. The ward clerk is out smoking, I think, in the ambulance bay with the other ward clerk — they have a mutual pact to quit before the New Year and are absolutely sucking out every last tobacco-filled pleasure — and since there is no else but me and the ringing phone, I pick up.
“Acme Regional Emerg,” I mutter as indistinctly as possible. I’m hoping they think it’s the pizza place down the road and call back.
“This is Hilda from Windy Sunset Nursing Home.”
Great, I think. “Yes?”
“You sent back a patient yesterday with orders for Home Care. He’s supposed to get IV meds once a day. Do you know him?”
Uh, no. In the first place, I wasn’t actually here yesterday, the warden granted a day pass, and secondly do you know what percentage of the GTA’s population we see everyday? And also I am getting worried. Being an old emerg nurse, I know Trouble when it’s walking on tiny cat feet, and this has all the signs and symptoms of being a tiger. Or at least a puma.
I look around. There is neither ward clerk nor charge nurse I can pass this impending mess off to. I sigh. Let me pull the chart, I say and call you back.
I hang up. I now officially own the tiger. Or puma. I find the chart,and yes, there it is. JM is an 89 year-old guy, bedridden, Alzheimer’s dementia in its last ugly stages, who has somehow developed an elbow cellulitis that has engulfed much of his left forearm. And hey, there’s an order for Home Care who’s supposed to administer Ancef 1 g IV OD x 7d.
JM has now entered The Republic of Health Care Stupid. It’s a funny little country, this Health Care Stupid. Governed by a cadre of bureaucrats, it’s presided over by a quasi-divine entity called “The Minister”, who lives in a gilded palace called “The Ministry of Health”, where she is fed peeled grapes and allowed out occasionally for ceremonial spending announcements and ribbon-cuttings. Its principal products are regulations and directives, consultant’s reports, and catered lunches.
What? You have no passport for this fabulous land? No matter. You don’t need one. And once you enter, you can never leave!
So. The Stupid:
Home Care steadfastly maintains that nursing home nurses, being nurses and all, can maintain IVs and administer IV medications, and refuse therefore to service nursing homes. And if the nursing homes can’t administer the drugs, then the patient obviously needs a completely unnecessary admission to hospital. Nursing homes (and their nurses), on the other hand, are equally resistant to actually learning how to start and maintain IV lines. As for IV meds — forget it.
Immovable object meet irresistible force.
In short, EMS will have to pick up the hapless JM, and he’ll spend a goodly chuck of his remaining time on this earth being shuffled back and forth between Windy Sunset and Acme Regional Emerg (and costing the system thousands of dollars in addition). This is because Home Care and the nursing home sector have squabbled like dirty chickens for the last 15 years over who actually has responsibility for patients like JM.
Clearly, this is Home Care’s problem, not mine. (It says so on the chart!) There are several Home Care case managers flitting around the hospital. They have a mysterious, near-mythological office up on the 5th floor that no one has actually ever been in. Rumours that a wormhole will suck in unauthorized personages and transport them to a desolate planet with endlessly windy plains presided over by a cold and lifeless sun, or Winnipeg, are, I’m afraid, unsubstantiated. At any rate the case managers are a pleasant, likely lot, except for one I not-so-secretly call La Crusty.
So I call up to the love nest, or particle physics lab or batcave or whatever they call their office. Of course, I get La Crusty, not the nice ones. I explain the problem, the Twilight Zone-ish Predicament of JM. Why exactly won’t Home Care go into nursing homes?
“Snarl, arf growls nutter hiss sbapz, because warf nurrzsarf, snarf, and gnash,” says Crusty.
I see. Well, since the order is for Home Care, maybe you need to come deal with this poor guy et famille because already I am getting very, verytired of this whole business, and hey, I just only picked up the phone. I have my own patients to take care of, though no doubt JM will be mine before the day is done.
Silence. Sound of La Crusty’s head exploding.
I hang up. Fortunately Social Work is hanging around. I am beginning to really love Social Work. Instead of standing around talking about why problems can’t be fixed and then deciding to hold a (fully catered) meeting or ten to discuss further why they can’t be fixed, she actually fixes problems.
In the end, the family has money, and they agree to hire a private duty nurse to come and give the drugs to JM in a fully staffed nursing home with nurses and everything, and with Home Care services available to any other citizen, so the poor guy won’t have the hell of laying on an ambulance gurney for seven days more or less continually.
Is this how our health care system is supposed to work? Really?