I picked up the first chart of the night and read the chief complaint. “Suicidal.” You never know what that means. It could be an old man who has sat all day with his shotgun in his mouth and finally thought better of the situation. It could be a belligerent drunk who was thrown out of his house by his wife and knows that he can stay in the hospital over night if he claims he’s going to kill himself. Or it could be a mixed up teenager who has experienced her first break up. It might mean a long work up and a lot of hand holding. Or it might be a quick “get out of my ER.” You just never know.
I suspect that I’m a bit cynical after years of manipulative behavior by those wanting ‘three hots and a cot,’ so I was a little surprised when I entered the room to find a calm, well-dressed young woman sitting on the bed. Her demeanor was one of sadness, not the flat expression of depression. After introducing myself to her I sat down beside the bed and asked as sincerely as I could, “How can I help you?”
“I just needed someone to talk to,” she said. I was busy writing on the chart the time I’d entered the room. I put down the chart and looked at her intently.
“Well, that’s what I’m here for.” I folded my hands and tried to focus on just her but I could hear all the chaos in the ED. I didn’t know how long I could afford to just sit and listen. “Tell me what’s been going on.”
“We live with my mother-in-law.”
“My husband and I and our little boy. He’s two.”
“She’s just so critical. I can’t seem to do anything right, according to her. She doesn’t think I’m a good mother to my little boy.”
“What does your husband say about this?”
“He’s afraid to upset her for fear that she’ll tell us to move out.”
“Why are you living there? Does your husband work?”
“Oh he’s a hard worker. But his plant closed down. And he can’t find any work in his field right now. We tried to hang on to our house. He’s working at all the day jobs he can find, but it’s just not enough. So we had to move in with her. She means well. I’m just getting tired of hearing her criticism.”
Seeing my opportunity to address the chief complaint directly and possibly start to take some action I asked her, “Have you been thinking of hurting yourself or anyone else?”
“Oh no, I would never do that,” she said with some surprise. This was consistent with my impression so far, but what about the triage note?
“The triage nurse wrote that you were suicidal. What did you tell her?”
“I just told her I couldn’t take this much longer.”
“You didn’t say anything about hurting yourself?”
“Oh no, I love my little boy too much to do something like that.”
“So let me be clear. You didn’t say anything at all to suggest that you might be thinking about killing yourself?”
“Oh no.” She was emphatic. “I told her I just couldn’t take this any longer. But I never said I wanted to kill myself or anything like that.” I was relieved, but frustrated.
“Well, OK then,” I said slowly while considering my options, “and please don’t take this wrong. But what exactly did you hope to accomplish by coming to the emergency department tonight? If there is something I can do to help I’ll be glad to do it. But it doesn’t sound like you have a medical emergency tonight.”
“I’m sorry to bother you with this. I shouldn’t be here.” She started to cry. I felt embarrassed for coming off as so hardhearted but I really didn’t know what to do to help her. Then I struck on an idea.
“Would you like to talk to one of the social workers? She might be able to help you work through some of your options for other housing arrangements. And if that can’t be done, she might at least be able to connect you with some counseling to help you cope with the situation with your mother-in-law.”
Her countenance brightened. “Yeah. I’d like to talk to a social worker.”
“I’ll see what I can do,” I said, already half way out the door and thinking about my next case.
“This’ll be a case you’ll enjoy,” I told Becky the night social worker when I finally got her on the phone. “This is not a placement. All you need to do is talk to this young woman about her options for moving out of her mother-in-law’s house. I know you’ve got all kinds of connections with the community. She’s not crazy. She’s not suicidal. She’s not an abuser. She just needs some good solid common sense advice. And I know you can give it to her. OK? Great!” Another problem solved. I felt good. Somebody might get some real help from social services tonight. I grabbed an arm full of charts and charged off to work up a “belly pain,” an “ankle pain” and a “short of breath,” which I decided to see first.
An hour or so later the nurse assigned to the psych rooms passed me as I rushed by. “I put an IV in the lady in Room 7 with her blood draws. Do you want anything else? And she couldn’t pee, so we just cathed her.”
“What? Who are you talking about?”
“Your suicidal lady in the psych room.”
“She’s not suicidal. And NO I don’t want an IV. And why is she getting blood drawn?”
“The psychiatrist won’t see her without medical screening and that includes a blood draw and a tox screen.”
“Hold everything.” I grabbed Becky as she walked by. “What’s going on with Room 7? Did she tell you she was suicidal?”
“No. But the chart said she was suicidal. I can’t talk to her and discharge her if the chart says she’s suicidal.”
“But I wrote on the chart that she completely denied all that.”
“I know, but once it’s on the chart, we have to assume that it’s correct and call the psychiatrist. You know, for legal reasons.”
“Oh, and can you co-sign these orders?” the nurse interrupted. She was impatient and wanted to get back to the backlog of patients.
I looked at the order sheet with a sigh of frustration. Since the psychiatrist didn’t come in at night, the patient would have to stay in the ED all night. Even if she wanted to go home, which she did, she would not be allowed to sign out AMA because of her complaint. Because she was “suicidal” she had to have a sitter to watch her to prevent her from hurting herself. In the morning, the psychiatrist would quickly discover the same information that I did and discharge her, but only after he had charged $300 for the consult. All totaled she might run up a $1000 bill that night, just for wanting to talk to someone. And if I tried to circumvent the system at this point and simply discharge the patient, it would surely be reported as a breach of care. I apologized to the patient for the inconvenience. I felt terrible for initiating this fiasco and I ruminated on it all the way home.
“Did you take out the trash last night before you went to work,” my wife asked as I munched granola and watched the morning news. I cringed as the commentator said, “Some experts suspect up to 10% of all the money spent by Medicaid is spent on unnecessary testing and treatment by doctors.”
“Fraud?” the anchor said in a menacing tone.
“No,” I said defiantly to the TV. “So go ahead and prosecute me already.”
“Hey Buster, I was just asking. You can lose the attitude or you’ll be wearing the rest of that breakfast.” She stood over me with raised eyebrows and coffee pot.
“Huh?” I was tired and confused. But something told me I had just dug the hole I was in a little deeper.
Mark Plaster, MD, is the executive editor of Emergency Physicians Monthly