My spry, 90-year-old patient decided she had a urinary tract infection two weeks ago. She had difficulty urinating and the constant urge to void with no fever, no chills, no back pain, no bloody urine. She was advised to come in for an appointment the same morning, but this didn’t suit her. The alternative choice was to see her urologist who made time available that same day. She decided this was not convenient either.
I called her and took a history and attempted to negotiate a visit but she declined strongly. She chose to void into a sterile container she had at home, put it into the refrigerator for storage and start to take some ampicillin that had been prescribed for her last urinary tract infection weeks before. One day into the ampicillin therapy she had her full-time aide drop the urine off at the office for a culture and analysis (It came back negative for an infection several days later). That night she could not void. She called the urologist, and the covering doctor suggested she drink more water. She complied even after she developed nausea and vomiting which continued into the early morning hours. Her aide called 911 and EMS brought her to the emergency department.
This frail, elderly woman has not been eating well for months. As her total protein drops and her activity diminishes decreasing her leg muscle tone, her lower extremity peripheral edema or swelling increases. Her veins drain less efficiently than in the past contributing to the swelling. She suffers from a chemical electrolyte regulatory abnormality with chronic low serum sodium. Vomiting electrolyte-rich material and replacing it with electrolyte free water further diluted and lowered her serum sodium.
Upon arrival in the emergency department, the ED physician noticed the swelling in her legs and reflex ordered a congestive heart failure (CHF) lab panel. The government (CMS) has made such a big deal about recognizing CHF that physicians and hospitals are afraid to not recognize it and not treat it. If you don’t treat it, there are financial penalties for the docs and the institutions. The CHF panel consists of expensive and sensitive heart muscle enzymes that elevate in a heart attack, a lipid profile and a BNP which elevates in CHF. The problem is that the heart enzymes and BNP elevate in a host of chronic conditions seen in the elderly unrelated to heart failure.
I was called into the hospital to evaluate and admit the patient in the middle of the night. A Foley catheter was now inserted into her bladder and draining fluid. Steps had been taken to slowly correct her sodium abnormality. A urine culture was sent with the initial catheterized urine, and the evaluation of her heart based on “indeterminate” heart enzymes was completed. She did not have a heart attack. She was not in heart failure. Her serum sodium rebounded slowly with a treatment called fluid restriction. Three days later she was voiding without the catheter, ambulating with her walker and aides assistance and ready to go home under the care of her aide and two daughters. She was scheduled to see me in 72 hours with the urologist to follow.
I called her the next day, and she was doing fine. The next morning when I called, she was constipated, so we instituted a program which using over the counter medications corrected the problem. At 3 p.m. the next day, she called my office and left a message that she wanted to speak to me. My nurse asked her if she was sick and she just repeated the need to talk to me. I called her when I finished with patients, and she told me, “I am dying. I am very sick. I feel like I have to pee and I cannot. I have called 911, and I am on my way to the hospital.” When I tried to determine what the definition of “very sick” meant she couldn’t elaborate. She was not febrile. She had no chest discomfort or shortness of breath; she just couldn’t void. I called the ED and spoke to the head nurse and physician and reviewed her recent clinical course and findings.
One hour later they called me to tell me she was in urinary retention and her bladder was overloaded. They placed a Foley catheter in her bladder, and 3/4 of a liter of urine emptied relieving her discomfort and very sick feeling. The problem was that the ED physician saw her leg edema and sent off the CHF lab protocol again. This was a different ED physician than the week before. This time the troponin I cardiac enzyme marker was in a higher in determinant range.
“Steve,” he said, “her EKG is abnormal. I think she is evolving a myocardial infarction and needs to be readmitted.” I reminded him that we had completed this exercise last week with her longtime cardiologist and her heart was fine. He told me he didn’t care. The risk medical legally was too high to send her home. The costs and hospital stay now start again.
This patient had daily 24-hour care by an experienced aide. Both her college-educated adult children were with her. She had my office phone and cell phone as well as access to the very flexible urologist. She still chose to do it her way, relying on EMS and emergency departments due to fear, anxiety and having no financial skin in the game. The urologist wondered why she didn’t just call him and he would have reinserted the catheter in his office. I wondered why she just didn’t call earlier so we could see her before my staff left for the evening. It didn’t matter if we were capitated, being paid for quality metrics or if the fee for service system was abolished. This strong-willed, independent complicated ancient senior citizen was determined to do it her way. The system runs on algorithms and protocols and generates information routinely that requires a common sense interpretation based on the clinical setting and issues. The risk of medical malpractice, despite government funding this care, plus the risk of government sanctions based on chronic disease protocols, makes intelligent and compassionate care which is affordable almost impossible.
Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.
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