Coordination of Care Requires Patient Input

As a general internist with a small concierge practice I have tried to coordinate my patients’ care and dealings within a complex, bureaucratic and dysfunctional health system. Patients have access to me 24 hours a day, seven days per week by telephone, cell phone, email and text messaging.  I do not have an answering service so all after-hours calls are forwarded directly to me.   During the initial patient orientation visit we discuss the need to keep me abreast of their health concerns and problems so I can bring the big picture to their immediate and localized health concern or problem.  Similar information goes out in my quarterly newsletter and is on my web site. I am trying to reach the technologically sophisticated patients as well as the technologically challenged.

I was somewhat surprised to receive a late Friday night call from the local ER to tell me one of my 86 year old cognitively impaired individuals was being evaluated. When I spoke to the charge nurse I found that the patient was brought by the paramedics for intractable nausea and vomiting.   This particularly charming, mild to moderately cognitively impaired, woman had moved with her 90 year old husband from her private residence to a senior facility on my suggestion so that care was available for her as she deteriorated and required more hands-on attention. They were thrilled with the new apartment as well as the care and concern provided by the staff.  I had seen the patient six weeks ago and she was doing fine. There was no mention of problems.

Since her last visit she had developed a dental problem. Unknown to me, her dentist extracted all her left lower jaw teeth and made arrangements for a periodontist to perform three dental implants.  The periodontist pre-medicated her, one hour before surgery, with 1 gram of the antibiotic amoxicillin because seven years ago she had a surgical knee replacement.  She then had the surgery and was sent home on Tylenol and codeine for pain.

She took her second Tylenol with codeine at home, went down to the community dining room, ate some chicken soup, felt ill and vomited several times.  The dining room staff just called 911 and transported her to the local ER.  I was called by the ER doctor after his evaluation to say he believes that between the large dose of oral antibiotic and the codeine, the patient became nauseated and vomited. He was prepared to give her some intravenous fluids and send her home.  After completing the IV fluids she got up to go home, became lightheaded and had another bout of emesis.   I was called back at about midnight and went in to evaluate her.  She looked fine but a bit dehydrated so I decided to observe her overnight while administering fluids and anti-emetics if she needed them.

I had no previous knowledge that this cognitively impaired woman with a limited future lifespan was having such extensive dental surgery.  There is much controversy about whether an individual with a prosthetic knee replacement even needs antibiotic prophylaxis with an antibiotic notorious for causing GI distress.  There were additionally concerns on my part about the choice of a codeine based narcotic for pain control based on her existing medication list.

Had the husband, patient or dentist called in advance to discuss this we could have come up with alternatives that may have prevented this hospitalization.  If the primary care physician is not included in the care plan and kept current, how can one be expected to coordinate care?

After evaluating the patient and making the arrangements for her to stay overnight, I expressed my disappointment to the patient’s spouse about not being informed of the impending dental procedures of this magnitude in advance.  He apologized profusely for not thinking to call me or asking the dentist to call me. He asked me to write about it in my blog to let the other patients know why they need to keep their doctor informed of all their health care comings and goings.

Guidelines for When to Call 911 First and When to Call Your Doctor

We are very fortunate to have a fine and well trained paramedic squad to respond to medical emergencies in Palm Beach County and the City of Boca Raton around the clock.  Additionally, patients of my concierge medical practice have direct have access to me 24 hours a day.

I educate my patients how to use the services so that they get the most appropriate attention for the medical condition they are experiencing.  Thus, it is important to have basic guidelines of when it’s appropriate to call 911 in a life threatening emergency.  All too often, 911 is called for non life threatening emergencies which can delay emergency response time to other families’ life threatening crises by diverting attention to their non critical situation.

I suggest my patients call 911 immediately if they, or someone they are with, experience any of the following:

  1. Breathing Difficulty
  2. Chest Pain suspicious of a heart attack or pulmonary embolus
  3. Loss of consciousness or change in mental status
  4. Uncontrolled Bleeding
  5. Severe Trauma creating the possibility of life threatening internal injuries.
  6. New and uncontrolled pain suggesting a major and severe injury or illness

In these situations, I ask patients to call 911 immediately and then call me if they are free and not attending to or providing resuscitation for the patient. When the paramedics arrive on the scene they will take the steps necessary to save the patient’s life. They will attempt to stabilize the patient and bring them to the nearest emergency room even if it is not the hospital of choice or the hospital where the patient’s physician has staff and admitting privileges.

In situations other than those mentioned above, when 911 is called, the paramedic unit is responding to a non critical situation. When doing so, they are unavailable to respond to some other individual’s life threatening situation.

In most cases, irrespective of their findings, the paramedic’s protocol will direct them to recommend that the patient be taken to the emergency department for additional evaluation. They often choose to take the patient to the closest medical facility not the one the patient would prefer to go to.  This often results in long and lengthy time spent in the ER waiting to be seen by the ER staff and undergoing numerous laboratory and imaging tests because the ER staff does not know the patient’s medical history.

I remind my patients to call me first in non life threatening situations so that I may intervene and direct the evaluation. I speak to the paramedic team at the site to judge the severity of the situation and to make suggestions to the patient and family.

When I meet the patient at the ER, I know my patient well enough to judge, without many tests, if they are sick enough to stay and be admitted. The process is facilitated by knowing the patient’s medical history and knowing what the patient looks and acts like when they are well.

Very often, instead of going to the ER, the patient can safely be treated in my office, their home, or the office of a colleague who specializes in the type of medical condition  they are experiencing. This saves the patient time and gets them the attention they need for their non life threatening situation without overloading an acute care hospital’s emergency department.