Every morning the hospital, we have a big meeting with all of the residents, nurses, and attendings from the entire floor. The ostensible reason is to make sure that everyone was on the same page about which patients are ready to go home, and to make sure that all the boxes are appropriately checked before they do so. In reality, I suspect that at least half of the reason is so that Dr. Khan, who runs the meeting, can review the troops, drill sergeant style. It’s a very formal, spit and polish affair, everyone decked out in white coats, standing around the largest nurse’s station, the only one large enough to accommodate the two dozen people who show up.
“All right, let’s get started. Room 401,” comes Dr. Khan’s crisp voice. One of the interns straightens up, takes half a step forward, and reports “This patient came in for a stroke workup, CT and MRI were negative. We’re awaiting the results of the echo, and once we have that back as well as a PT evaluation, they shall be ready for discharge.”
“All right. Call the cath lab and make sure the patient’s on the schedule today.”
“PT, you’ll be able to see this patient today?”
The physical therapist, a grizzled veteran of the hospital, barely leans up from his paperwork and says that yeah, he’ll see the patient this afternoon. He, of course, is outside the medical chain of command and has nothing in particular to fear from Dr. Khan, and always seems quietly amused by these proceedings.
And on it goes to room 402. It someone else’s time to jerk to attention, and God help you if you miss your cue even by a couple of seconds. The whole thing takes about 45 minutes, and it’s just one of those things that you grin and bear as part of the job.
One day, we got a call from the ER that we were admitting a patient who was sent to the hospital from a nursing home for “altered mental status.” This is a pretty broad symptom that includes anything from a little forgetfulness to confusion to being in a coma. And usually, you need to take a very careful history and to identify exactly what has changed recently, and what might be causing it. Ideally we’d also ask her family members, because they have the best sense of how the person’s thinking has changed over time
In this case, though, it wasn’t exactly a mystery. As soon as he walked into the room, she started shouting “Where’s the baby? WHERE’S THE BABY?” and wouldn’t calm down for another five minutes.
Well, we had our mystery, and we immediately started to do the medical workup for altered mental status, which is pretty extensive. A lot of things can cause this sort of presentation, anything from a stroke to an infection to a psychiatric disorder. (You’d be surprised how often elderly people develop new mental illnesses – it’s not just a young person’s disease.)
Ultimately, both the CT and the MRI were normal, which pretty well ruled out stroke. The blood cultures were negative for any infection, but we had been treating her with antibacterial and antiviral medication just in case. The hospital’s psychiatrist got wind of this case and paid her a visit one afternoon. I’m not sure what exactly they talked about, but he slunk out of the room less than five minutes later, gave a long, multisyllabic sigh, grabbed the chart and wrote “please rule out medical causes and re-consult psychiatry as needed.” Translation: “your patient – your problem.”
While all of this was going on, she was sitting outside the room, accosting anyone who’d walked down the hall with more questions. “Where are you going? Come back here! WHERE’S THE BABY?” Usually this was just an occasional annoyance, something you’d chuckle uncomfortably at and laugh off as you walk past. But the one time we couldn’t avoid it was during Dr. Khan’s rounds. Every morning we’d start filing into the hallway around the nurse’s station, right in front of her room, and you could see her eyes widen as the hallway outside her room filled with a sea of white coats. As the last stragglers filed in and the hallway fell to silence, Dr. Khan would clear his throat and start, “Okay, let’s get started. Room – ”
“WHERE’S THE BABY? WHERE’S THE BABY?”
Her self-control, never that great to begin with, would give way. A nurse would rush over to her chair and try to calm her down and after a minute or two she would be pacified enough for us to continue. And another minute or two later, when some poor intern’s in the middle of getting grilled, she’d burst out again. “WHERE’S THE BABY?”
Dr. Khan gave us a look. It wasn’t an angry look, or even a frustrated one. It was an incredulous look – “wait, patients can actually do the sort of thing? On my rounds?” It was all we could do to keep from bursting out laughing.
Ideally, once we’d ruled out the most common culprits, we’d want to get a lumbar puncture – a spinal tap – to retrieve a sample of the fluid in her spine and brain to make sure there is no infection there. But she was incredibly anxious, and would start hollering and thrashing around as soon as you spoke to her, so sticking a needle in her back was not exactly going to be a simple operation.
First we chased down the neurologist, who routinely performs this procedure all throughout the hospital. With our best pretty-please-with-a-cherry-on-top voice, we gently suggested that at this point in the patient’s workup, might it be a reasonable time to consider getting a lumbar puncture in this patient? The neurologist adjusted her glasses, looked us up and down a couple times as though wondering if we were the ones presenting with altered mental status, and said “gentlemen, with the way she is thrashing around on the bed, I really don’t feel comfortable doing a procedure at this time.”
Next, we called interventional radiology, where they have special expertise in doing these minimally invasive procedures. But when we tracked him down and told him the story, he took a deep breath and said “look, we really don’t just want to be the LP guys for the whole hospital. Try anesthesia first, and if they can’t do it, then get back to me.”
By this point it was getting late in the afternoon and I was getting pretty desperate. I wasn’t even sure if the anesthesiologist was still there in the hospital, and if we couldn’t get this LP, there was no way we’d ever be able to send this lady back. The nursing home representatives would come out, take one look at her, and say “Wait, so you’re telling me that you gentlemen with your fancy degrees and white coats that only can’t fix her, but didn’t even do a complete workup on her?” Then they have a stern word with Dr. Khan, and Dr. Khan would have a stern word for me, and I’d spend the rest of the year mopping the floors, which wouldn’t be so bad, really, if not for the fact that every time I walked by her room I’d trip over my own feet when she let loose with another “WHERE’S THE BABY?”
But no, fortune was with me, and after a few minutes of phone tag I managed to get ahold of the anesthesiologist and breathlessly explain our plight. I waited with bated breath, but after a few minutes all he said was “okay, bring her down.”
The art of getting a patient into an elevator when she’s thrashing in a wheelchair, hollering “WHERE’S THE BABY,” and occasionally grabbing at doorways and passersby, is not something they teach in medical school. It ultimately involves a great deal of reassuring, deflecting her grabs whenever possible, and even singing some soothing songs. By the time we got her down the hall and into the elevator I felt I’d both aged a decade and been forcibly inducted into the mysteries of fatherhood.
But we got her down there, and sure enough, the anesthesiologist was able to get the procedure done with minimal fuss. We sent the fluid down to the lab for analysis, and I headed home for some well-deserved rest.
The next day, before we could get any of the lab results back, we finally succeeded at another arm of the investigation: getting in contact with the patient’s daughter so we could let her know that her mom is in the hospital. I carefully explained her mother’s condition to her, and described all the medications that we started her on and all the tests that we’ve tried. I asked her if she had any questions.
“You’re doing all that for my mom?” she asked.
I smiled warmly. In a time when patient’s families often expect us to work miracles, it felt really good to bask in the gratitude of a patient for whom we really had gone above and beyond. “Yes, of course,” I said. “It is a bit of a challenge to take care of her, at least when she’s in the state, but all of us are really coming together to do everything we can to make sure she gets the best care. It’s really just part of the job, and she deserves nothing less.”
“But why all the tests? She always acts like that.”
I suppressed the urge to swear. So she didn’t have some incredibly mysterious infection. This was just normal dementia which she’s been having for years and years. Someone in the nursing home either didn’t get that message or decided to send her to the hospital anyway. All the work we did in the last week, and all that she had endured in the course of these tests, was chasing after a mirage.
I took several deep breaths. I thanked her for her time, promised to update her as things progressed, and told her to call us if she had any questions. Then I had a terse conversation with the nursing home manager. Later that afternoon, an ambulance arrived to take our patient back to the nursing home.
The only silver lining of this saga is that for the rest of the rotation, I could make my resident jump two feet in the air by creeping up behind him and shouting “WHERE’S THE BABY?”
I did not try this with Dr. Khan.