Once upon a time in a land close to Trenton, New Jersey, a handsome ER doctor named Hans Flowerbottom was presented with the complicated case of 86 year old Shlomo McKenzie, an elderly patient with advanced dementia sent from a nursing facility to his local ER due to altered mental status. It was his last patient of his 12 hour overnight shift, and Dr. Flowerbottom needed to get out of staying late at work as he had a golf tee time later that morning. He had to disposition this last patient….and fast! On arrival, it was found the patient was seemingly acting differently than his normal self. According to nursing home staff, Mr. Brown typically was able to state his name, his age, and sometimes can feed himself. This time, however, he was off by one year on his age, although his birthday was apparently last week. Subsequent ED workup included a CBC, electrolyte panel, troponin, EKG, chest X-ray, head CT, and a urinalysis. Unfortunately, none of these tests could figure out what was wrong with Mr. McKenzie!
Then family arrived. They stated that Mr. McKenzie does not like the nursing facility he is in. Apparently, the cafeteria food was undersalted, the nursing staff unpleasant, and the toilet in his room was only cleaned once a day! The family stated to the doctor that under no circumstances would they allow him to be sent back to “that hellhole.”
Dr. Flowerbottom needed to think fast. What was he to do? He knew that trying to send this patient home or to another facility would involve getting social services or case management involved in the ED, and that would extend his shift. And he just had to make his golf tee time later that morning! He did not want to sign out this patient to the oncoming physician because, frankily, that guy was a dick when it came to “signout payback.” For example, last time he left the guy a difficult signout, he was paid back his next shift with a signed out LP, 2 pelvic exams, and a malignant drug seeker whom he had been avoiding for over 4 hours.
He had to find a way to admit this patient. And it had to be convincing. And quick!
During the repeat physical exam, Mr. McKenzie coughed one time. That made Dr. Flowerbottom think back to the stapled pack of 6 sheets that accompanied Mr. McKenzie from his nursing home documenting his past medical history. There, at the bottom of page 4 staring him in the face between “history of wrist contusion” and “treated in 2001 for UTI” was the diagnosis – “history of bronchitis!” Dr. Flowerbottom knew at that moment the patient’s mental status change had to be due to a recurrence of a normally self-limited, likely viral, URI he may or may not have had several years ago! Eureka! He called the hospitalist and explained that this sickly nursing home individual had acute delirium caused by a severe, overwhelming, recurrent upper respiratory tract infection that warranted admission. And it worked! The patient was admitted, Dr. Flowerbottom made his tee time, and everyone lived happily ever after. The End.