Sunday, February 25, 2007

Granny dumping....the nations favourite pastime

You know theres always a small part of a doctor's brain that sighs very loudly when they pick up a patient's notes and see the age of the patient (over 65) and then complaint of either "Collapse query cause". Or "Chest pain". In fact theres a special scoring system which gauges the "heartsink level" for elderly patients. This is how it comes about :-

Level of depression doctor experiences = Age of patient x (complaint vagueness score* + Home Situation**)
- multiplied by 5 if they were brought in by ambulance
- multiplied by 10 if Dementia is listed on the front of the notes
- multiplied by 20 if they were brought by relatives on/prior to a public holiday e.g. Christmas Eve

* complaint vagueness: "Collapse ? Cause" = 2 "chest pain"=3 "fall"=4 and "unwell" =5
** Home situation: Own home = 0 Living with relatives = 5 Residential/Nursing home =8

The reason for this is quite simple. "Young" people just don't like old people. How ridiculous has society become that the elders are not only not respected and looked after properly but are treated quite badly in some instances. Don't get me wrong, I and other doctors actually enjoy the challenge of seeing elderly patients with multiple medical problems (yes we do need to get out more, more on that topic in later posts) but what irritates and saddens most of us are the circumstances surrounding the majority of elderly patient admissions.

The saddest thing I have personally seen (and very naively thought was just a medic-myth) is the phenomenon of Granny Dumping. Let me enlighten those of you not familiar with this concept

Granny Dumping [gra-nee dum-ping] v.
1. To abstain from the responsibility of looking after an elderly relative often because you "can't be bothered", "they smell" , "you want to have fun and go out with your friends" by way of fabricating medical symptoms which guarantee admission to hospital at least for one evening.

2. To relieve yourself of your nursing/care duty for one/several residents for an evening or two by fabricating medical symptoms which guarantee admission to hospital for at least one night often because "they smell", "they are incontinent", "they are confused", "you don't like them" or you're plain lazy and uncaring.

3. A selfish act to ensure your party or public holiday is enjoyed to the maximum at the expense of an innocent party who may have been your own carer when you were younger but you have conveniently relinquish all knowledge of the countless times you had your nappy changed and vomit cleaned up. Usual dumping ground :Local hospital

The last 2 years I have had the joy of working on Christmas Day. Not only was I depressed at having to work and make do for lunch with a soggy sandwich or nothing at all but I was made to feel sorry for the high number of "grannies" dumped in a cold-hearted and selfish manner. The stories whether from nursing homes or from relatives practically drooling at the thought of not having to take grandpa to the loo again were strikingly similar. It would always be...He/She was just sitting at the table and then collapsed and was foaming at the mouth. Or He/She was sitting there and then started having breathing difficulties and was clutching his/her chest and looked in agony. Or he said he had chest pains. Or he looked really unwell and vomited.
Problem is with all of these patients they are unwell...they are elderly, frail, with multiple medical problems and risk factors for serious problems such as heart attacks and strokes and these "symptoms" cannot be ignored, even if the patient themselves do not remember it occuring. Sadly it is not only a Christmas-related problem, its year-wide but more apparent at that time.

The worst cases are those coming in from Nursing homes, brought in by ambulance with nursing staff saying they just became "unresponsive" for x amount of time. As all "good" doctors know its very important to get a detailed history about such events, also known as a collateral history.
And here is what happens to me (unfortunately) on a weekly basis.

Me- "Hello there, this is Dr No No calling from Somewhere Hospital regarding a patient of yours, may I speak with someone who looks after them"
Nursing Staff - "Um you want what? Vat Eez it? Who patient?"
Me- I'm a medical doctor looking after Mr Unwell, please can I speak to the nurse looking after him to discuss what happened today
NS - "No you cannot. Dat nurse is gone now. No one here who knows dees tings. "
Me - "What? No one there who knows about this man? But he just came here one hour ago!"
NS -" No, Dey have gone. Sorry"
Me - "Okaaaay, well perhaps you can look in his personal notes there as we did not receive any information. At least tell me what his regular medications are and what he is like normally, you know like how he mobilises and whether he is confused for example...."
NS - (laughing)...."Dey are all confused here, you know Eeez old"
Me -(starting to get slightly annoyed). "Yes I understand that, can you please find some information for me, as it is quite important"
NS - "Well he is only here few weeks we do not have anytings on him- maybe dee manager will come and say it in morning. I cannot get that stuff "
Me - "Not even his medication list and allergies?"
NS - "Oh Dat, let me see I will come back in 1 minute okay?I av to check it"
(I hear rummaging around and 6 minutes later...)
NS - (Triumphantly) "Here it ees. okay he has At...At....ha ha it is hard to read it ateen- ateen-oh""
Me- Atenolol?
NS- Yes dats it fifty oh dee. And den Ato heehee...Ato- voh- state-een Ten"
Me (getting inpatient and frustrated) You mean Atorvostatin? !!.....

And so it goes on, the painstaking task of getting information out of someone who doesnt care, doesnt know the names of the medications she is feeding to someones "loved ones" on a daily basis and just wants you to go away so she can get back to her nap. She is the one that people entrust with the care of their parents in the hope that they will be looked after in a decent and supportive manner. The reality is not always like the Nursing home brochures would have you believe. Half the time no-one will pick up the phone and a lot of the time the people allegedly looking after the patient don't even know what their normal state ought to be, so how on earth they can be expected to pick up on the sometimes subtle changes in a person who is actually sick? Sometimes patients will arrive in hospital so unkempt and soiled that I wonder if they are having any care at all!

I'm sorry to depict the Nursing staff as foreign and inept, but sadly this is often the case and I don't think it has anything to do with their ethnicity [Note I am a second generation foreigner but my family members have excellent verbal communication skills and are respectful and educated and understand the significance of their respective careers and the effects on others- very much lacking nursing home spheres] . It seems that the people setting up some of these residential and nursing homes will take on "cheap labour" from people whose English is just not good enough for the job (Just think most of these people have trouble hearing the perfect pronounciation and English of the newscasters on must be pretty frightening to not be able to communicate any problems or wishes to someone looking after you). The nursing home owners (businessmen and women) don't really think about quality of care of the human aspect of the service they provide. They just make sure that granny looks clean when daughter comes to visit and time the feeding assistance in line with the scheduled relative visits to give the false impression of good care.
Anyways, I digress...the point was that when these "nurses" (I often wonder if some of them have ever had any training...I spoke to one who had never heard of Aspirin recently) get bored or annoyed with cleaning up urine and faeces and feeding then they pull the- "Send them to hospital" stunt....wasting ambulance and hospital time for a patient who is as well as they always were and will be.
Every cloud has a silver lining...and as a result of multiple presentations of dodgy cases from the same homes...something is being done and investigations of some homes are in the pipeline. I really hope they get shut down or fined or something. Its just so frustrating because that shadow of a person lying on the hospital trolley dazed, confused and smelling of a urinary tract infection mixed with faeces is someone/was someone and is entitled to a better life. Its really a sad reflection when you are over the moon when you come across a decent cooperative and well informed member of staff when you call up a home (it does happen from time to time!)

Granny dumping.....this Christmas, let grandma sit in the corner talking to herself....and maybe feed her a bit of mashed turkey and potato puree. After all...she did the same for you when you were babbling away incomprehensively all those years ago....


kingmagic said...

A well written treatise on the scurge of certain nursing homes and the granny dumping effect.

In general the homes are sorting things out because of their duty of care, but some still plod on regardless and show minimal effort in having an holistic caring package for the residents.

Another dumping effect on A/E is the GP referals. Time and time again people are ringing their GP and then being told to ring 999. I understand if this is for chest pains or unconsciousness or a severe injury but not for a catheter problem or a cold!

"Hear and treat" is no replacement for "see and treat". Yesterday I attended a male in his mid fifties with a history of lower back pain for three weeks. He rang his GP who said ..."in my expert medical opinion you should be in A/E, please dial 999".

So, off we go to the patients house on blues & twos, and within 5 minutes of arrival we found him to be suffering from a UTI due to a recurring blocked catheter (last changed Dec 06). He had been diagnosed with the UTI the night before and prescribed ant-biotics and pain killers.

We told/advised the patient to give the anti-biotics a chance to kick in and keep taking the painkillers as they seemed to be working. We then rang the local District Nursing team and arranged for a catheter change later that day.

Result..patient happy (staying at home), us happy (now available for more serious jobs), A/E happy (avoidance of an unneccessary admission.)

Nothing more annoying than people passing the buck. Glad to know that there are some good docs out there.

ecparamedic said...

See? ECPs do have their uses!

I know in time the dumpers will get wise to this and invent Sx that we can't rule out or treat on scene.

You depiction of the conversation with 'care home' staff was spot on. Simple questions are met with blank looks, many don't know the patients names (apparently). It's like a breath of fresh air to walk into a good one, but they seem to be further apart these days.


Shindaru said...

I would like to find some statistics on this issue.

please email if you have any

Anonymous said...

There are several sides to this taking care of your elderly relatives. My father deserted his family 50 years ago. I had to go to work at 11 to support myself, wear the neighbors cast off clothes, etc. I had it tough -- but I raised myself as my parents refused to take care of their child. A month ago, the government called and wanted me to take in my father who deserted me 50 years ago. I didn't do it. I had to take care of myself as a child so my father can take care of himself as an elderly, confused person.

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shaheel said...

Chest pain is considered a chief symptom of heart related problems. It can occur due to various causes such as heart attack, pulmonary embolism, thoracic aortic dissection, oesophageal rupture, tension pneumothorax and cardiac tamponade.

By conducting several medical tests, the above causes could be ruled out or treated as recommended by medical professionals. If acute chest pain occurs, the patient should be admitted immediately for observation and sequential E.C.G.'s are followed up.

Just like in all medical cases, a careful medical history and detailed physical examination is essential in separating dangerous from minor/trivial causes of disease. Sometimes, there is need of rapid diagnosis to save life of patient. A deep study of recent health changes, family history, tobacco consumption, smoking, diabetes, eating disorders, etc. is useful in treatment of chest pain.

Features of chest pain could be generalised as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; pain coming from exertion; dizziness; shortness of breath and a sense of impending doom. On the basis of these characteristics, a number of tests can be carried out for proper treatment. X-ray and CT scan of the chest help in determining the basic cause of pain. An electrocardiogram helps in detailed study of the problem.

Anonymous said...

Thank you for this article. It brings home the many selfless acts that Doctors and other health care professionals do for their patients. Bravo!

When watching the Michael Moore movie, "Sicko", I was in tears over an old lady dumped by cab and wandering the sidewalk in front of a hospital in her nightie. Someone's daughter, someone's sister, auntie, mother - left to fend for herself nearly naked.

Sort of reminds you of the pets people abandon in rural areas so the "farmers" can take care of them.

Young and beloved, they're tossed out like Christmas trees when age sets in.

Who ever could have imagined a disposable society?