Success? A Discharge Plan in Two Parts

The patient: A few months ago I had a patient. Obesity, diabetes, and high blood pressure had taken their usual toll, and she had been just barely getting by in her tiny senior apartment.

The obesity caused aching joints and fatigue, so her mobility had become increasingly limited. Her sleep had been poor thanks to the extra weight that makes it difficult to breathe fully when lying down. The diabetes, poorly controlled, had led to poor circulation and neuropathies in her feet and legs, meaning she had very little feeling down below her ankles.

You can imagine: poor balance and bad falls, cuts and scrapes that go unnoticed and untended, etc. The long and short of it is that the combination of these factors led to two massive heel pressure wounds. One on each foot. She didn't notice because they didn't hurt. Truthfully, her heels were falling off. Especially the left one. Folks, it was gross.

So, her sister drags her to the ER, she gets admitted and seen by the wound care specialist. They decide: 1) admit her to rehab to try and get diabetes and blood pressure under control (this will help healing), 2) Apply fancy dressings and regular cleanings for a week and then decide whether she needs surgical debridement (yes, in the end, she did), 3) NO WEIGHT BEARING ON HER HEELS, FOR 2 MONTHS.

My part: Okay, I'm going to give the short version. She wanted to go home, not to a skilled nursing facility (SNF). Our original plan had been for skilled nursing because she lives alone and can't get around on her tiptoes because, not to put too fine a point on it, she weighs 400 pounds. Also, she can't feel her feet well enough to know if she is actually staying off her heels. However, she was adamant. No SNF.

So we thought up a plan: Bariatric (medi-speak for obese) hospital bed, bariatric drop arm commode at the same height as the bed, setup of the home with computer, tv, food, water all accessible from the bed. Then hire help for 1-2 hours in the morning for wound care, light cleaning, help with toileting. Then, train her to do safe scoot transfers from the bed to the commode. Then recommend home care until her wounds healed. That's it. We did pretty good.

But then, the local home nurses association (HNA) said that they absolutely refused to take her on as a patient. "She belongs in a SNF" they said, "she needs way more help than 2 hours a day" they said. They were surprisingly pissy about it. So we went back to the drawing board, we enlisted the sister to be a caregiver 5 hours a day, we got her in and trained her to do everything from butt wiping to wound care, we argued, we got Doctor Smith to call the head of HNA and insist that they follow through on the doctor's orders. In the end, they did, gracelessly. It was clear from their eval note that they were looking for problems and they planned to have her taken to the ER at the first sign of anything off. They wanted her to fail.

So 3 weeks later, when she still hadn't turned up at the hospital again, I naturally assumed that all our efforts had paid off.

The rest of the story: So just last week I was talking to one of the lovely charge nurses. She is an evening shift nurse and I was telling her about some current patient whose discharge plan I am worried about. She responded "yeah, we don't want another one like 'X'" referring to my no-heels patient. I was stunned and asked her what on earth she was talking about. This is what she told me.

6 hours after arriving home "X" calls the rehab unit complaining that her catheter isn't draining and she is having pain and cramping in her abdomen. This charge nurse answers and gives "X" instructions to feel along the tube until she finds the kink, then unkink.

"X" calls back 10 minutes later, couldn't find a kink. Charge nurse says to call her sister, the one we all trained to be an excellent caregiver (guys, we worked REALLY hard at this). "X" sounds dubious but agrees to try this.

10 minutes later she calls back saying her sister isn't coming and she's just going to call the ambulance and go to the ER. The nurse says to wait a few minutes, hangs up, and calls the doctor (at home because it's now 9 o'clock at night)

Nurse: Dr. Smith! We can't have our discharge go to the ER, THE SAME DAY, because of a kinked catheter.
Dr. Smith: Oh shit, fucking shit... [more swearing].
Nurse: You know what, I'm just going to go over to her house and see what's going on.
Dr. Smith: yeah, go do that, please.

So she goes. She finds "X" in a sweltering hot room, windows closed, drenched in sweat. She explains how you might not have anything to pee if you're sweating everything out. She opens windows. Around the time she arrives the sister also shows up. 3 sheets to the wind. She drove across town to help out, stumbled in and sat down to watch our charge nurse fix things up. So our nurse gets water, she gets a cool washcloth, she checks the catheter. Everything's working out... so she thinks.

But then, as the nurse about to leave "X" says (are you ready for it?): "oh hey, since you're here, could you help me with this bedpan? I've been on it since I got home." That means 7+ hours guys, lying on a bedpan, that her sister had apparently put under her and then left. For the night. (This raises so many questions for me I just don't know where to start... what were they thinking? why didn't "X" remove it herself- which, incidentally, she could have done? wha.. whe... I.. uh...)

"X" rolls onto her side and, to the nurse's consternation, the bedpan goes with her. She goes to remove it but can't. Because in the last 7 hours gravity and liquid (squeamish people should stop reading now) have successfully suctioned it to "X's" butt.

"Ot-girl, I could not get it off" she says, pantomiming prying at something with a foot and both hands. In the end she resourcefully dug out a metal spatula from the kitchen and used it break the seal. She said it went off with a shot-like report. And a spray of poo instantly decorated "X" and her bed. The sister watched impassively.

At this point our nurse sort of lost it. Thrusting the steaming full bedpan at the sister she starts reading them the riot act about getting their act together. She talks about how everyone has gone out on a limb to get "X" home because this is what she wanted, she talks about our hard work. And she talks about their hard work. She finishes by reminding them that HNA will be out there the next day looking for an excuse to fail "X" at home and send her to a SNF. Then she makes the (drunken) sister empty the bedpan and clean everything up.

She gets back to work at 11pm.

As I'm listening to the story I'm thinking: "Oh my God, HNA was right. How could I have been so wrong? This chick should NEVER have gone home!" I'm horrified.

On the other hand, she's still at home, 5 weeks later.

So actually, I have no idea what lessons to draw from this adventure.