The Last Thing On Our Mind

She was having excruciating pain in her pelvic area.  I pulled the sheets down cautiously and noted the bruising encircling the waist and inching towards the thighs.  I finished my exam and retreated to the nursing station of the skilled nursing facility to comb through the chart.  ER records, floor notes, consultations, but no X-ray of the pelvis. There was no mention of pelvic pain.

The emergency room physician had dutifully ordered a cat scan of the head and neck to rule out injury.  The hospitalist had noted a fourteen point review of symptoms.  The social worker had informed the patient that she was admitted as an observation.  He made sure a discharge plan was in place before two midnights which effectively meant that the patient would foot the bill for her whole rehab stay.  Notes upon notes documenting that the patient was not able to return home.  But no mention why.   She couldn't walk.  She couldn't walk because she was having excruciating pelvic pain.

The next day the X-ray confirmed my suspicions.  She had a pelvic fracture.  I called the nurse and ordered an orthopedic consultation.  Although I knew that she would not need surgery, I felt that they should examine her and comment on weight bearing status, etc.

Of course, it was only hours before the director of the nursing home was calling me on my mobile.  No orthopedist in the area could fit the patient it.  Furthermore, the nursing home was doing an investigation and had to prove that the fracture was a result of the fall that brought the patient into the hospital and not an an on site injury.  The wrath of the state weighed heavily on their minds.

So they wanted to transport the patient back to the emergency room.  Document the injury, get an orthopedic consultation, dot the i's and cross the t's.  Don't worry, they will send her right back!  There was no consideration of the cost of such deliberations.  No concern for the discomfort or pain that the patient would have to suffer.

So this is what we have come to in medicine:

Shoddy, rushed hospital care.
Offloading costs from Medicare to the patient.
Bending backwards to meet the requirements of the state.

And the comfort and suffering of the poor patient lying in the bed in front of us,

the absolute last thing on our minds.