The Doctor Will See You Now [Non-Fiction]

Chapter 70: Geriatrics

I inherited a case after the previous resident transferred away. Dot is a 85-year-old woman with dementia, heart disease, high blood pressure, diabetes, and is generally just old and frail. She is discharged a few weeks back and readmitted several days after with cough and sputum, diagnosed as Hospital-Acquired Pneumonia (a chest infection acquired during one's stay in hospital -- which is why we try not to keep patients in hospitals for too long).

During one of the septic screens where we look for a source of infection, which includes blood, urine, and sputum culturing, we grew a super-resistant bug called MDRA (Multi-Drug Resistant Acinetobacter), probably acquired during Dot's prolonged previous hospital stay where she had a lot of antibiotics for her infections. The lucky thing is the MDRA in her urine is just living there doing very little. Her urine doesn't show any white cells or nitrites. In the elderly, this is called asymptomatic bacteriuria where bugs just live in the urine happily, not causing the host harm, much like the bugs that live in our gut on a normal basis.

We treat the chest infection (which was what brought her into the hospital to begin with) and when that is over, I call the son, inform him of the cured chest infection and the urine bug finding and our plan to not do anything about the urine bug unless Dot were to become unwell from that. He seems to accept that and agree to a weekend of observation and then home on Monday.

On Monday, the nurse tells me the son is furious. I'm confused; he seemed perfectly amiable and pleasant on the phone on Saturday. I call him to find out what's wrong, only to be lambasted by him.

"I got told about this MDRA business and now no nursing home will take my mum because she needs an isolated bed. So you need to treat her."

I tell him that I treat based on clinical need and his mum isn't sick.

"What do you mean she's not sick?! This is a really bad bug! It's so bad she needs isolation!"

I explain that she needs isolation because that bug could be a risk to vulnerable patients like our other inpatients and nursing home residents. It's not a risk to her currently. If she gets sick, like with a fever or gets confused, then I'll assume it's the bug and then I'll treat. She's well right now. No fever. White cells are normal. So I won't be treating.

He does not like that. He shouts at me that our hospital is rubbish. Our healthcare is rubbish. There's no way we are unable to treat a simple infection. Well, obviously it's not a case of our inability but rather the lack of clinical indication. He says, seeing as we are unable to treat, we must therefore refer her to another tertiary public hospital 2 hours away by car for further treatment by experts.

I must? What the eff? No, you don't get to decide whether we refer a patient on or not, especially when there are no indications. He's free to take her to that hospital's A+E once she's discharged if he wishes, but we aren't writing anything for him. Plus, we're every bit as expert as any other public hospital of the same specialty. Our expertise is not for him to decide.

"Look, if we treat the bug when it's not hurting now, we run the risk of growing something else that's even more resistant, more difficult to treat, and if your mum gets sick from that because I was carelessly treating every bug she grows, she might even die from it because at that point we run out of antibiotics."

I may as well speak to a wall. He goes on again about the resistant bug. How we 'have to' (I don't 'have to' do anything, thanks) treat because the nursing home won't take her. And he is feeling unwell now because he's had contact with her and he's worried because the bug is so resistant to antibiotics.

What?

It's not an indication to treat just so he can find a nursing home to put his mother when she's not sick from it.

Also it's not an indication to treat her because he's so worked up he feels sick. He just has to wash his hands.

Also also it's not my business he's sick. He can go see a doctor. And not visit his mother in hospital if he's so sick.

But obviously he's kicked up a big fuss now so there's no way to discharge Dot even though she's fit to leave the hospital. I offer a second opinion, to discuss this with my senior (which I've actually already done during my previous ward rounds) and if he agrees with me, then we still will not treat. The son agrees. He also tells me he's in the process of filing a complaint against the other hospital who previously treated his mum.

I don't see the point of this mention. It has nothing to do with the current conversation, so I just went "uh-huh" and reiterate that I'll talk to my senior. Just because he's complaint-happy isn't going to influence my clinical decision.

Actually, I do see the point of his mentioning the complaint. It's a common control tactic used by family members who are aggressive and lack understanding of clinical management. We aren't doing things their way so they try to control it so we do.

Obviously my senior thinks the son is insane and there's no way we need to treat asymptomatic bacteriuria just because he can't find a nursing home for her or just because he demands it.

More shit hits the fan because we aren't telling the son what he wants to hear. He makes an official complaint against me. We hold an official meeting as a result, including my boss and the complaint committee representative.

Son tells us we 'have to treat the MDRA'. My boss tells him we don't have to, from his point of view, although he offers to get microbiology involved and see what they advise and we'll follow that. The son agrees.

Boss asks him what the son's plans are once Dot is fit for discharge, whether she's going back home or going to a nursing home for respite or for long term. Son says he has to go on holiday soon for a few weeks and will need to see when he gets back. (I'm not quite sure what the holiday will change about her discharge destination.) Boss encourages him to make a decision early because nursing homes can take time to organise space and the longer Dot stays in hospital, the higher risk she is at for developing hospital-acquired infections. That last part clearly flies over the son's head as he starts to get angry at us again for mentioning the word 'discharge'.

We offer a backup plan to have Dot in the hospital respite ward for a little while pending discharge destination and we can redo her urine check later to see if she naturally clears the bacteriuria as some folks do (and hints that we still won't treat the MDRA). Son agrees with that. Face it, of course he would. He doesn't have to pay for her hospital stay but he has to pay if she goes to a nursing home.

Microbiology does eventually come and see the patient and says the same thing as me. No need to treat asymptomatic bacteriuria.

Dot then develops a fever a few days later, likely a hospital-acquired infection. We are now three weeks past the day when Dot was first fit to go home. We regrow everything. No MDRA in her urine but there is another bug, E. coli, one we can (and will) eradicate. I phone the son to tell him of microbiology's advice and the latest urine results, emphasising that we haven't grown the MDRA again (although that doesn't mean it's cleared from her system). I chase up the social worker on the discharge plan once that infection is cleared. Apparently, the son has told her that Dot has to stay in hospital 'for further work-up and treatment of her MDRA' so the search for a suitable nursing home is on hold. It's literally like we never had that big meeting in the first place and it's the same 180-turn he did to me after that first phone call. I roll my eyes so hard I saw my brain.

Dot goes to the respite ward awaiting a nursing home, her care now off my hands. But nursing homes will still require isolation rooms for her, because that label lasts for several years. Even when she no longer grows MDRA.