“Bed blocking generates problems throughout the health-care system, from longer wait times in the ER to poorer health outcomes for patients from accelerated functional decline, social isolation, and loss of independence,” wrote Dr. Jeremy Petch, an expert in biomedical ethics and health policy at the Li Ka Shing Knowledge Institute at Toronto’s St. Michael’s Hospital, in a 2012 blog entry at healthydebate.ca.
According to wisegeek.net, bed blocker is primarily British, Australian and Canadian slang. The circumstances and the reasons may be somewhat different, but bed blocking is a growing concern in the United States as well. Bed blockers cost hospitals as much as $1,500 per patient per day. The added financial burden threatens the already shaky financial viability of publicly funded hospitals in the U.S.
Given the stress on the system that these patients cause, physicians’ antipathy toward them begins to make sense. Take it as an article of faith that internists are the hospital physicians most likely to have bed blockers on their wards. Still, it’s a term that disturbs budding geriatrician Dr. Nathan Stall. “These patients are not in hospital because they want to be there, and they’re not trying to cause a problem to the system,” says Stall. “I think, really, the system is failing them.”
In Canada, the “fix” for bed blockers is to designate them for placement in a nursing home by reclassifying them as Alternative Level of Care, or ALC. It’s a way of shuffling the patient off a team’s list of acute care patients. The term reminds me of what Fortune 500 companies do when they write off bad loans and delinquent creditors. ALC has become the new name for GOMER. In the Bunker, the designation is cause for celebration. “Often, there’s definitely high-fiving when someone is made ALC,” says Nathan Stall. “That’s an accomplishment. They’re pretty much off your list.”
Once that happens, the patients no longer receive active treatment and blood testing. They may not even have their vital signs monitored. Stall knows of instances in which the care of such patients is so neglectful that they suffer serious complications. “The team kind of pops their head in once a week. I know that geriatricians have said that these patients have been horribly mismanaged—things that people have not picked up on.”
Something like that could be happening to a loved one of yours who resides in that limbo state between acute patient and nursing- home resident.
“I’ve seen things where something more aggressive could’ve been done but more so the typical geriatric preventive measures could’ve been done,” says another resident, who didn’t want her name used. She recalls a patient who was admitted to hospital by an internal medicine team. The patient was bedridden and spent his days lying flat in bed. “His wife was feeding him while he was lying down, which put him at great risk for aspirating his meal.”
The patient stopped breathing; he had to be placed on a ventilator and ended up being transferred to the ICU, where he died. What bothers the resident is that the death could have been prevented by having the patient sit up during meals. “I have this horrible feeling that maybe one simple thing could have saved his life,” she recalls.
* * *
From the foregoing, you might be tempted to think bed blockers don’t exist in the U.S., a view that is depressingly untrue. In some places, including New York, Texas, Florida and California, there’s a growing list of bed blockers that are next to impossible to remove from hospital wards to nursing homes.
In January 2012, the New York Times reported that hundreds of patients have “languished for months and even years” (that’s right, years) in New York City hospitals, despite the fact that they are considered by doctors to be well enough to be discharged or at the very least discharged to a nursing home. The reason? The patients are illegal immigrants.
Under New York state law, if patients don’t have a lawful address, public hospitals aren’t permitted to discharge them to shelters or to the street. And while Medicaid pays for emergency care for illegal immigrants, it does not pay for long-term care. The result is that such patients—like their ALC brethren—remain in limbo in acute care hospitals for years. One such patient in New York has remained in a hospital on Roosevelt Island for a staggering thirteen years, according to the aforementioned New York Times article.
Bed blocker is a polite term for such a patient. At one of the top hospitals in America, they called them rocks. “A rock is a patient that cannot move because they’re just stuck,” says a resident in internal medicine who agreed to speak to me only if I withheld his name. “If we have a lot of rocks, we call it a rock garden,” he adds.
An attending physician in the ICU at the same hospital told me that rocks are not uncommon at the hospital because farms in the region hire a lot of illegal immigrants who arrive with no money and no family to care for them.
The attending ICU doctor recalls a case from early in her career that taught her a lesson about the dangers of uprooting rocks. The patient—an illegal immigrant from Mexico—had a bad accident and was admitted on a ventilator to the ICU. Eventually, he recovered enough to be transferred to a long-term care facility. As was the case with other such patients, the man had no insurance.
“We have trouble getting our regular patients on ventilators, who have insurance, into a facility,” says the attending doctor, whose identity I’m protecting because of what happened.
Having no place in the U.S. to send the patient, the hospital arranged to transfer him on a ventilator—which he depended on to be able to breathe—to a hospital in his native Mexico. They got the man’s family members to come to the hospital to accompany him on the journey home.
“We got the patient back to Mexico on the ventilator,” she recalls. “And when he got there, the hospital immediately disconnected him from the machine,” she says. As a result, the man died of asphyxiation.
In the U.S., we might call what was done at the hospital in Mexico manslaughter, if not premeditated murder. It was a hard lesson for the doctor who told me the story.
“It was real eye-opener for us because we had spent all this time and energy getting it arranged,” she says. “We don’t do that anymore.”
Instead, they let slang terms like rock and rock garden express the frustration they feel about these all-but-immovable patients.
* * *
Doubling the frustration about the patients they can’t remove from hospital beds, doctors are also frustrated that they had to admit them in the first place. There is a strong thread among residents and attending physicians that GOMERs just aren’t worthy of their knowledge, their skill and their time. They label such patients as suffering from “failure to cope.”
Often used to describe over-anxious patients, failure to cope is also used to describe GOMERs who are not particularly ill and (if younger and more able bodied) could almost certainly be sent home. But age and infirmity have made the patients unable to master a new diet or a new regime of medications, or to attend follow-up appointments.
“They’re not eating and drinking as well as they should and not looking after their personal hygiene,” says Dr. Nooreen Popat, until recently a resident in internal medicine at McMaster University in Hamilton, Ontario. “So they need to come into hospital and be looked after by some allied health-care personnel, or perhaps have the social worker get involved.”
Some residents don’t have the luxury of calling on a social worker. Instead, they have to perform many of a social worker’s functions, which makes many bristle.
“I feel like failure to cope is a very derogatory term in that it is blaming the patient for some sort of failure,” says Dr. Amanda Gardhouse, a resident in internal medicine at McMaster and one of very few young physicians committed to becoming a geriatrician. “Our system is not designed to deal with all the multiple medical issues that geriatric patients bring to the table. We’re not really sure what’s going on, so we’re going to call this failure to cope. It’s very sad.”
Andre
w Burke, who trained in internal medicine at McMaster, refers to failure to cope by two other slang terms. “Well, that would be a ‘social admission,’” says Burke. “Someone with a ‘positive suitcase sign.’”
Just about every doctor and nurse has heard if not used positive suitcase sign—sometimes called the positive Samsonite sign in reference to the manufacturer of luggage. The phrase takes a clinical trope—positive in medicine means the presence of an abnormal finding (for example, “the urine dipstick test was positive for blood”) and combines it with suitcase to create a slang term that means the patient made an unscheduled trip to the ER but had time to think about packing a suitcase.
“In the emergency department, a ‘positive suitcase sign’ literally means when you go in to see a patient, you see their suitcase on the floor,” says Dr. Rick Mann, a family physician. “The patient or the patient’s family have already determined that the patient will be coming into hospital—regardless of what their diagnosis is or whether there is or is not a medical problem.”
The reaction among emergency physicians and nurses to the patient with a positive suitcase sign ranges from amusement to profound irritation.
“One of the frustrations is that there isn’t necessarily one clear thing that we can do to solve failure to cope,” says Dr. Clarissa Burke. “You know it isn’t just a matter of fix your knee pain now, you’ll be able to walk around and do everything. They still wouldn’t be able to look after themselves.”
Another reason the positive suitcase sign bothers physicians so much is that it’s perceived as a demand to be admitted to hospital—and as a direct challenge to the doctor’s authority to decide. The patient or family member who insists that the patient be admitted may become known as demanding—but patients will not be admitted on demand.
If you’re thinking of bringing a suitcase to the ER, best to leave it in the car.
* * *
Frustration about having to care for patients doctors think don’t require their knowledge and skill animates much of medical slang. But even recognizing that requires some insight on the part of physicians. All too often, they search the patient for small medical problems such as a bladder infection or a slight drop in hemoglobin or sodium levels. These problems sound serious; in reality, they’re trivial because they don’t harm the patient. Fixing them won’t make the patient better, but will earn the doctor some money and a sense of accomplishment.
There’s a nickname for such behaviour, says medical resident and future geriatrician Nathan Stall. Call it “kicking the can down the road.” To a team of residents, kicking the can down the road means fixing little things yet doing nothing substantive to address the reasons a patient was admitted to hospital. “We kind of tidy them up,” says Stall. “We say they have an acute kidney injury, so we give them intravenous fluids. We put them on antibiotics for pneumonia. We hear a heart murmur and so we order an echocardiogram.
“But their main problem might be this complex functional psychosocial thing and we’re just in such a rush, and too overburdened to do it, that we don’t actually get to the problem that’s causing these people to come to the hospital.”
Stall says he sees residents and attending physicians play kick the can down the road almost every day. An example that sticks in Stall’s mind is of an old woman who had fallen and broken her pelvis. She was confused and delirious. “Her admitting doctors heard a heart murmur and ordered an echocardiogram,” says Stall. “They were rehydrating her with intravenous fluids. They were testing her urine to see if an infection was the reason why she was delirious.”
All of these actions made it seem as if the doctors were taking good care of the patient. Stall says they completely missed the underlying issues that made the woman fall and break her pelvis in the first place. As Stall dug deeper, he learned that the patient had gone downhill during the past year following the death of her beloved pet, a cat who was the woman’s main source of companionship.
“The woman was depressed, so she stopped going for walks,” says Stall. “That made her less in shape and more likely to fall. To sit down and actually figure out what was wrong with her was not actually that challenging, but the difference that it could make on her life is huge.”
I’ve heard doctors say they don’t have the time to delve into the factors that make an old man depressed. I would suggest that the real reason isn’t lack of time so much as a lack of interest in fixing the problems that bring frail seniors to hospital in growing numbers.
Kicking the can down the road epitomizes the search by doctors for medical diagnoses that either don’t exist or aren’t worth fixing. Sometimes, doctors try to fix things that either can’t or shouldn’t be fixed. The slang term used to describe that is flogging.
Dr. Zubin Damania says he first heard of flogging in connection with patients who are war veterans. The Veterans Administration (VA) operates the largest integrated health-care system in the United States. It has more than 1,700 hospitals, clinics, community living centres and other facilities. Damania cut his medical teeth looking after veterans from the Second World War and more recent conflicts.
“They had every single chronic disease in the world,” says Damania. “They had PTSD [post-traumatic stress disorder] and all the other stuff that goes with it and they all were smokers. So they were super-enriched with pulmonary disease and end-stage congestive heart failure. As veterans, they didn’t ever want to give up. Their families never wanted to give up. So we just flogged somebody with treatments. It was totally counterproductive, but it would keep them alive.”
The word flogging has been likewise adopted by residents and attending doctors in internal medicine in reference to GOMERs. Duke University Hospital pulmonologist Dr. Peter Kussin says he first heard it during his own residency in New York City. “One of my teachers in pulmonary would put it in his notes and on his admission orders,” Kussin remembers. “We knew exactly what he meant.”
As Kussin recalls, flogging had a humorous yet therapeutic meaning—to give a patient with asthma several different kinds of drugs to try to relieve his shortness of breath, as in pulling out all the stops.
There’s treating a patient aggressively to try to stave off death. Then again, there’s treating a patient unto death. Even that concept has its own slang term: cheech. According to the online Urban Dictionary, cheech is “ordering every radiologic and lab test imaginable to diagnose a confounding (or at some institutions, not-so-confounding) illness. In noun form (also known as cheech-bomb), it refers to the panoply of tests itself.”
Damania says he heard cheech and flog a lot when he went to med school at the University of California at San Francisco. “It means every single medical intervention is going to be done to this guy until he cries uncle or the family says, ‘No, no, no more,’” says Damania. “The cheech was often done to GOMERs, but it didn’t have to be. We often flogged a GOMER or flogged somebody who wasn’t a GOMER. It all kind of swirled in the same yucky mess of doing things to people instead of for them.”
An attending ICU doctor at one of America’s top hospitals told me the famed medical facility has been known to cheech patients. As one of the major health facilities in the southern United States, the hospital frequently gets referrals from smaller, rural hospitals to transfer patients who are beyond hope. “We accept these patients knowing there’s nothing we can do to save them,” she told me.
And when that happens, the doctors at the leading hospital feel they need to justify accepting the patient by performing all manner of invasive tests—even redoing ones that were done quite competently by the referring hospital. Keep in mind that by definition, these patients are already sick and near death.
I think the doctors would do better to have a realistic chat with the family about the patient’s prognosis.
* * *
Of all the modern synonyms for GOMER, the most pointed one goes right to the heart of the
matter.
“You’ve probably heard the term failure to die, haven’t you?” Dr. Donovan Gray asked me rhetorically. Gray, a veteran ER physician in Winnipeg, Manitoba, with more than twenty years of experience, is author of the book Dude, Where’s My Stethoscope?, a collection of short stories about his career and his view of modern medicine.
Failure to die (FTD) is a play on the bona fide medical phrase “failure to thrive,” which refers to an infant—and sometimes a frail elderly patient—who is unable to maintain an ideal body weight. Gray says he has heard it used many times by general internists and emergency physicians. “The mind is long gone, but the body is chugging along,” he says. “Maybe [the patient] gets pneumonia or something.” The table is set for a fairly quick and painless death—except nobody told the patient.
“They just keep on going for weeks and weeks or months,” says Gray. “You’re just thinking that it would be so much kinder for this person to pass away. It’s a bit grim but it is accurate.”
FTD is not the only phrase that captures the sense among doctors and nurses that such patients are simply putting in time until they expire. At some hospitals, these patients are called walkers—the term used on the popular TV series The Walking Dead to refer to zombies. Walker is a bit of irony, as the vast majority of walkers are bedridden.
In The House of God, Dr. Stephen Bergman introduced slang to describe patients at or near the end of life. “O Sign” refers to a patient so far gone that her mouth remains open in the shape of the letter O. A variant of the O Sign is the Q Sign, in which a patient’s tongue protrudes from the side of the mouth, forming the letter Q. Both slang terms are still used widely by doctors and nurses.
Kris Schultz, an oncology nurse with more than a decade of experience in Massachusetts and, more recently, in Georgia, recalls a colleague filling her in on a patient. “She kind of shrugged and said that he’s starting to exhibit the Q Sign. She turns to me and does the face. I remember giggling hysterically—so much so that I had to quiet down because there were patient rooms right outside of the nurses’ station and I didn’t want anybody to think I was laughing at the idea that somebody was dying.”
The Secret Language of Doctors Page 10