Some Health Issues Should Not Be Evaluated in the Office

I received a phone call from an elderly gentleman who was closer to ninety years of age than 80, was taking an aspirin and had just suffered a fall and hit his head. He did not know why or how he fell. He asked for an appointment the same day to “check me out.” 

My staff asked all the pertinent questions and immediately brought the information to me.  After reviewing it, I felt for his safety his best course of action was to immediately call 911 (or have us do it) and go to our local emergency department for evaluation. The patient takes daily aspirins to prevent a second heart attack or stroke.

The antiplatelet action of the aspirin, plus his age and the head trauma necessitate an immediate and thorough evaluation with imaging. I do not have an X Ray unit, CT Scan unit or MRI unit in my internal medicine office. If I bring this gentleman into my office, he must transport himself, wait until I have time later in the day and probably will then have to wait to be scheduled by an imaging facility for a non-contrast CT scan of the brain to make sure doesn’t have a bleed between his brain and skull or a bleed in the brain. The delay in evaluation can threaten his survival and recovery. 

The patient was quite angry at the suggestion – quoting my concierge practice contract that says we will bring you in for a visit same day for an acute condition. The non-stated content is that we will bring you in same day for a condition that is appropriate for evaluation in an office setting. The same can be said for someone calling with acute substernal chest pain which could be a heart attack or sudden inability to breathe.  Add in excessive bleeding that does not respond to compression or loss of consciousness as conditions that are best evaluated and treated in an emergency department. These are all conditions that require a call to EMS via 911 and an immediate evaluation in an Emergency Department where the equipment exists to quickly evaluate and treat these problems safely. 

The patient was worried about the wait in the ED and COVID-19 exposure. Both concerns are understandable despite little transmission of Covid recorded in ED visits or in patient hospitalizations.

This patient has emailed me twice now demanding a full refund of his membership fee due to violation of the contract. The reasoning and concern have been explained to him several times already. My concern is that his new onset short temper and grumpy demeanor are the result of the fall and head trauma which still has not been evaluated.

Patients need to know that there are times a health issue requires evaluation and treatment in an emergency department.  It has nothing to do with a contract.  It has everything to do with making the right clinical recommendation for the patient.

Evaluating a Patient’s Ability to Live Independently

As a geriatrician in a locale with many elderly retirees, I am frequently asked how long mom or dad (or both) can stay in their home and live safely and successfully.  It is clearly a complicated issue even if the individuals involved are cognitively and mentally intact, physically capable and financially able to pay for support and help.

There is much to consider. Are the patients physically able to maneuver within their household safely?  If sleep is being interrupted constantly by the night time urge to urinate, can the patient safely navigate the trip to the bathroom without suffering a fall? If they get to the bathroom can they easily manipulate a standard toilet?   If they need to clean themselves and bathe can they get in and out of the shower or bath without falling and injuring themselves?

Fortunately there are elderly home experts who will travel to the home and evaluate it for safety.  They make an assessment and provide a written report to the patient and the ordering physician. Many of these safety personnel are specially trained home health company nurses sent into the home by the patient’s physician. In many cases, Medicare or the patients’ insurance will cover the cost of the evaluation. Once the evaluation is complete, they will suggest certified and responsible contractors to do the home safety alterations.

While our goal is always to keep the patient in their home if possible there are many issues other than the safety of the physical plant to consider. One needs to consider how much supervision and assistance the patient needs to perform their normal activities of daily living?  Can they dress and groom themselves independently?  Can they prepare meals for themselves and clean up after them?  Can they get to the store to shop for food and supplies?  Can they get to their doctors’ appointments? What happens if they become injured or ill?  Do they wear a device which allows them to call for help if they are immobile and cannot get to the phone?

The option of paying someone to care for your elderly loved one is quite expensive. It will cost a minimum of $15 per hour to supply inexpensive help. You may need more than one person so that the staff has time off for their personal needs.  Some families choose to hire a companion who in exchange for room and board supplies help and supervision. This is always risky especially if you don’t/cannot check the background of the individual you are inviting into the home.

If you can afford to pay for help and to alter the home for safety there is always the issue of socialization. Many of my patients who have lost their mates have also lost their friends. They no longer have someone or a group to pal around with.

One particularly spry 93 year old patient was still playing golf, going to the gym and aerobics class three days a week and playing cards regularly. Her golf foursome and card game participants all had passed away or moved closer to their children for support.  Although she had the finances to hire a wonderful aide around the clock she was lonely for companionship despite living in a large country club on a golf course.   She became a wonderful candidate for the correct assisted living facility with a broad range of social activities and residents of a similar age looking for companionship as well.

These are complex issues which require the assistance of the individual’s physician in most cases. It is important for the individual to choose and retain a physician who will take the time to talk to family and professionals involved in the enrichment of their lives.