As a hospice case manager, some of you should be calling hospice instead of 911. Your loved one will legitimately live longer on outpatient hospice then in the hospital. And bonus they will be more comfortable.
it's the stigma associated. people fear death although it's a natural part of life and I probably don't need to tell you that's all they think about when they hear "hospice"
It's in the nature of Medical professionals, whose job is (broadly) to control illness by monitoring, deciding and responding, to come to believe that their ability to shorten the time in that loop is the best way to improve patient outcomes. That is so often true - stroke or anything acute cardiac, for example. And it's reinforced by patients who don't understand the medical world - for whom there is no difference in comprehension between a complex medication regime and a magical potion. Everyone WANTS to believe in the power of the hospital to fix everything. But it's not always true, and you're right to call it out. What you point out about the nature of risk is dead on, and it flies in the face of the belief in the infallability of the Doctor's power to control for the better. Medical staff aren't magicians, you can't control everything, and the very incomplete list of very real risks you pointed out MUST be assessed on a patient-by-patient basis. To do anything less is to betray the very point of 'doing medicine'. Bravo, Preston.
@@An-Chliste it's taken me a while for the depth of your compliment to sink in. The idea that my reply here leads to that conclusion is high praise indeed. One of my deepest core beliefs is that the cure for fear is knowledge. One of the reasons I follow @itspresro is because he passionately gains knowledge and shares it with the same passion. More than half of patient advocacy can be summed up as "make sure the patient can understand what's going on to the best of their ability - and structure your care for them to give them as much choice as possible". To that end, Preston seems to be a natural patient advocate - contextualising information meaningfully.
@benforno3354 I agree with you fully. I am humbled and truly honoured by your kind, sincere, and deeply-considered response. Preston, as you stated, is someone I, too, appreciate. His posts are truly impactful and meaningful. As you and he suggested, nosocomial infections are rampant in the hospital setting as are those individuals who are ignorant of the abilities of medical science and the limitations of said "magic". (Borrowing from your previous comment.) I spent my career(s) educating others in the military, hospitals, clinics, universities, and simply in pursuit of the routine of an average day with anyone who asked a question or sought knowledge that I could share or impart. I did/do so as a military officer, LMHC, RN, PhD, Professor, and as a Disabled Veteran. I believe we all have our "gifts" and we do best in life by selflessly sharing those gifts with others. I have seen the Power of this Love throughout my life, as a recipient and as a provider. I know that sharing brings our universe into "balance" (pardon my abbreviated concept here). Please, keep Shining your Light! You help to illuminate the universe (and most certainly our planet)! One might not ever know the impact we have upon others, human or otherwise. Yet, we Shine most Brightly when we Shine with true intention and when Love is our Foundation. May you continue to find Wisdom and Joy along your journey and may your Blessings continue to be Bountiful! Thank you for Existing!
Omg this!!! I was literally thinking the other day how much safer it would be if older patients from nursing homes who get a UTI could just...get treated for the UTI at their nursing home?? Like there are private duty nurses who can insert an IV and any LPN can be retrained on how to manage IV therapy if they need IV abx. The risk for delirium in the unfamiliar and frankly chaotic hospital environment is so goddamn high that any effort made to treat them at home would be 100x better than dumping them in the ER. Our gridlock is so bad, one of the hospitals I float to has an entire section devoted to patients who are waiting for a bed and are STUCK IN THE HALLWAY NEXT TO THE EXIT TO ICU. If someone were to cook up the perfect recipe for delirium, that would be it.
@@Hahaha-px5ep They don't necessarily, that was really more of an example of the most extreme case. When I float to rehab/complex continuing care floors patients are usually started on oral nitrofurantoin for suspected UTI before urine cultures come back. You could argue that IV therapy is less preferable in patients at risk for delirium because it is one of the minor aggravating contributors to delirium.
Not everyone that age is in nursing homes. My mother is 80 and lives with me. She's more active than me (I'm in a wheelchair, but she's still more active even if I weren't in one). She gets UTIs often and her urologist and PCP both have wait times too long and it would create sepsis (she's had that twice from waiting, once involved a 2 week hospital stay with one of those weeks in ICU). The walk in clinic near us told her they're not dealing with her because she has multiple antibiotic allergies and they've twice put her into anaphylaxis with the wrong drugs (one that both the DR and the pharmacist should have realized was a Sulpha relative, which is listed on her charts as being allergic). The clinic said they refuse to treat her any more and send her to the hospital ER for treatments. Her PCP and urologist (we've tried multiple at this point) refuse to allow her to have a standing prescription for when she gets a UTI even though there's only like 2 drugs she can take for it safely. It pisses me off that everyone drops the ball on this one. I'm used to bad medical care for my disabilities but it pisses me off for something so simple they can't just treat her via telephone and call in a script since it's the same drug they use every time. As for prevention, she tries her best but is unable to fully empty her bladder due to genetic conditions plus prolapse. Drs say she's not a candidate for catheters because of the shape of her bladder it wouldn't make things any better. She drinks a lot of water but it's still a matter of WHEN she gets an infection, not IF she gets one. ETA: her insurance refuses to pay for at home nurses or telehealth programs, and as I said before, the doctors involved refuse to hand out antibiotics without her peeing in a cup first even though this has been an issue for over 30 years.
Its a tricky situation because people often go on the other extreme end where they won’t feel the need to go to the hospital no matter how sick they are
@Autipsy... Sadly, for many Veterans, they have learned this avoidance behavior in part from their military service, being considered wimps if they seek medical care, and in part because the VA system is extremely complicated, slow, and not always the best care. Also, every day, there is a new and even worse revelation that fraud, waste, and abuse are taking place or being perpetrated by, to, or against the VA. There needs to be better oversight and accountability. Please, keep voting for the right politicians who understand the military and VA systems.
@@An-Chliste completely agree, its just always surprising when our vets come in with reaaaaally severe stuff going on that the civilian population would have gone to the ER for months ago
I work with people who have a tonne of trauma from being in hospital (extremely confusing, uncomfortable, can't smoke, anxiety provoking, no one to come with them or take them home, not in their own space, chronic conditions that make it hard to leave hospital etc) and getting them to go to hospital is not always possible. Yet the doctors don't want to provide healthcare at home, because the safest route is hospital. It's infuriating and disempowering. I'm in the UK too and it would literally save money to keep people out of A+E
This is such an important point. Hospitals aren’t going to do a lot to help your 85 year old grandmother with dementia who is getting more confused. Hospitals are super dangerous places where you’re constantly getting needles, labs, tests. Some of which have major side effects that are harmful.
Internal med NP here, and I can’t tell you how often families tell me they came into the ED for one small thing and ended up having goals of care discussions for their loved ones. Such a great point you make here, P!
EMS cannot initiate transport refusals. We MUST take you to the hospital unless you initiate and decide not to go. In the case of grandma, she can’t make decisions, so now it’s the families decision. We still cannot do anything about this if the family wishes to send grandma to the hospital. And attempting to convince them otherwise could actually be seen as “outside the scope of a paramedic” and you could potentially lose your license and be sued.
And imagine they're demented (or otherwise with no capacity to refuse) living in a nursing home ... Nursing home doesn't want that liability, they're sending that patient out.
@@hssnnkimYes exactly. Nursing homes will often send out their dying DNR patients with us and instead of dying in bed with potentially options for palliative care at the SNF, they die in the back of creaky bumpy ambulance and we have to figure out what the hell to do about it
Man, I am so impressed with the way you’ve transitioned this channel. I still think it’s hilarious, and it’s the right thing to do, although your skits are still awesome. Just curious, is your residency director aware of your posts?
Literally all our pts end up getting UTI or URTI or loose stools after around 3 weeks of admission. And fever for the patient bystanders. It's a given.
Valid. I have multiple chronic disabilities that will sometimes make it extremely difficult for me to care for myself and cause concerning symptoms. I would frequently need ER trips as a child (pre or early on in diagnosis) where I’d ALWAYS be discharged with a “idk all the tests are fine and you’re not dying. 🤷 go home and call your primary/specialist” 😑 I’ve given up on ER/hospital trips, even if I’m having a severe flare up, because they’re never helpful. I’ve even had ER docs tell me to “walk it off” when I broke my hip in 3 places and was unable to sit myself upright or go to the bathroom unassisted… at this point I feel like even if I WAS having an emergency I wouldn’t go to the ER because I can never tell when it’s something I should be concerned about, is the “same old, same old”, or just a new symptom development of one of my many conditions. If I do call a nurses line and mention my symptoms (usually high HR, palpitations, seizure-like episodes, joint pain, limb weakness, facial droop, etc.) and even clarify that these are likely related to my known conditions but just want to make sure it’s not something I should be worried about, I’m told to come into the ER “just to be safe,” then almost immediately discharged and told I’m just being anxious even when I’m not…
I mean he is in psych so the majority of patients this would apply to do not fall under his typical patient population. If he were an IM doctor maybe it would be different.
80 year old patients on Warfarin. Let's make their life more dangerous. It's dangerous enough being elderly where you can break a hip at any step. (I'm a pharmacist so I see this a lot.)
I used to work in the UK as a Paramedic for the NHS - we had excellent training and guidelines on what we called "non conveyance". For example, for a stable 85yo with a mild UTI, I could call a community team over to prescribe abx. It was safe and most importantly, patient satisfaction was awesome. Sadly, it was poorly funded so actually getting hold of community resources was a challenge.
Australia, Victoria. We have Virtual ED (doc telehealth) to prescribe E-scripts after pt review for non-emerg and have recently introduced the Paramedic Practitioner role to alleviate some of this. interesting times
My 96 year old grandmother fell after getting dehydrated from diarrhea, and had to spend a night in the hospital. A brilliant doctor decided to give her laxatives (genius) and Ativan to sleep, despite her being fine mentally and her chart clearly stating that she cannot take Ativan (she hallucinates and becomes agitated for an extended time). All we got from the nurses was “oh it’s our policy to give older people benzos”. I suspect they perform bloodletting on trauma patients too.
