Thursday, January 1, 2015

Merrily We Troll Along

Chronic readers of this blog (whom I trust are taking some kind of medication to control this) know that I have an affinity for coming up with new and different ways to objectively triage our patient populations.  I would be remiss if I gave the impression that I was the only one involved in this critical work.  One of my colleagues who has a special interest in the recidivist nature of some of our clients has been expending considerable effort in developing what she calls the Troll Score.  She has graciously invited my participation in the effort and, as I am always willing to advance medical science as long as it doesn’t involve me being instrumented in any way, I have most modestly agreed to help. 

Trolls are those patients who feel at home in the ER.  We want to ER to be a comfortable place, somewhere that people with illness or injury can come without fear.  However, we don’t want it to be too comfortable, as we have no desire to adversely impact the booming homeless industry.  The ER is like a highway overpass, a safe place to pull your car off the road during a downpour, but not someplace you should like so much that you set up camp and stay.  Trolls live under the bridges all the time, every now and then surfacing just long enough to snatch a tender young goat from the road above and drag it down to it’s doom. 

We all have our favorite trolls, those whose lives revolve around each ER visit and who, when discharged, simply can’t wait to get back.  Sometimes a troll returns not by choice, but because he has too.  If you ask most of our intoxicated citizens, they really would be perfectly happy sleeping it off wherever they fell.  Because most of them fall in the street, however, the police feel compelled in the interests of road safety to bring them in.  But many trolls also seek opportunities to come to the ER.

I’ve got two favorite trolls, one in each category.  In the first group is a one-legged man named Gene.  Gene gets drunk outside a specific convenience store (“You know, the one where all the Indians hang out.  The feather Indians, not the dot head ones”) and lies down.  When the police wake him up, he gets mad and fights, usually by taking off his artificial leg and swinging it about.  The way you deal with him, of course, is to put his leg in the corner out of reach and put him in three point restraints (because there’s no fourth point) and let him flail his stump like a grounded seal.  Four hours later he wakes up, is as pleasant as he can be, declines your offer of an admission for detox (“I’d like to tell you I'm interested, but I got be honest and tell ya it’s just not so”), puts his leg back on, and goes out to face a bright tomorrow.

Barbara is in the other category.  Barbara comes to the ER once a twice or week complaining of shortness of breath.  She has emphysema, so she's always short of breath, never any better, but never any worse.  But she likes Denzel Washington, and out hospital has a version of Movies On Demand for patient rooms.  So she calls the ambulance which brings her to the ER, it takes us about an hour and a half to prove that she is not having a medical emergency, which is just enough time for her to have a sandwich, a Sprite, and watch “Remember the Titans,”  When the movie's over we tell her to leave, and she says she can't go back to the death trap that is her home, and I point out that she's still alive so it can’t really be a deathtrap after all or she'd be dead.  She scowls and calls a taxi.  I was a little worried because we didn’t see her for about three months, and was afraid maybe, at long last, she was right.  Not to fear.  She’s back.

Drug seekers are a special kind of troll.  You can find something quirky or amusing about most true trolls.  Drug-seeking pseudo-trolls have no redeeming features at all, and the race is to see how fast you can get them out.  Preferred techniques are to tell them how many times they’ve been in the ER and ask if that number is excessive or to point out that other doctors have expressed concern about their use of narcotics, and you’re going to honor that concern no matter how many times they say their cousin stole their prescriptions.  Phrases like these are objective and factual, but clearly send the message that there’ no Lortab for you.  A true ER doctor feels a certain measure of success when a drug seeker comes to the ER and leaves as soon as they find out who will be their doctor, because it means that they are less likely to come back.  In a job where everything is transient, you can finally have a long-term impact.   

(The “cousin” line is actually pretty amateurish.  There are a lot of better ones.  It’s always fun when the patient blames us for cutting his pants off in the ER that had the prescription in his pocket, or that the police took his bottle of pain pills from him in jail and simply will not give it back.  But one of my all-time favorites was the guy who said he had loaned his car to a friend to drive to Mexico, only to find that he had locked his narcotic pain medications in the glove box where he kept them for safekeeping.  “He’ll be back next month, but in the meantime I’ve got this pain…”)

But back to the Trolls.  The Troll Score is used as a triage measure of the chances that you will actually be able to affect any change in the patient’s condition during the ER stay.  The value of such a score is immediately apparent.  In these days where rapid patient turnover is prized by hospital administrators and decreased costs are dear to health care policymakers, being able to know from the first moment you step into the room if your care will make any difference at all to overall outcomes allows to minimize your time with the patient and pare the costs of care to a minimum.  After much reflection…well, some at least…here’s what I’ve developed.

Troll Score:

Suspected alcohol level > 300, yet patient is fully awake and alert     (5 points)

Number of stool softeners     (Multiply x 2, 1 point apiece)

Number of ER visits within a twelve month period     (1 point each. Immediately double if any visits to two or more other ER’s within sixty miles)

CT scans of any type over last two years (1 point each.  Add 20 points if patient glows)

Statement that patient has “fired the doctor”     (10 points per physician)

Statement that “the other hospital treated me badly”     (10 points per hospital)

Any use of the word “disability” (10 points per qualifying condition)

Normal vital signs despite complaints of severe pain, trouble breathing, vomiting, fever, or parasitic alien infestation     (20 points)

Any mention of fibromyalgia.     (20 points.  Add 10 more each for associated irritable bowel syndrome, chronic fatigue, or a prescription for gabapentin.)

Any behaviors that imply a working knowledge of "The Great Big Purple Book of Crazy," otherwise known as the DSM-V (20 points)

If I’ve done this right, we should end up with a scale that plots out like a logarithmic curve, with higher scores representing those patients with a lower chance of finding anything actually wrong and therefore the least chance of making an impact on their disease and final outcomes.  Once validated, the physician could look at the score and say to the patient that the evidence (because we’re all about evidence-based care, right?) suggests there’s nothing we can do for you and would you please go home.  Turnover time minimal, negligible costs.  And maybe actually communicating to patients an educational message about their use of the ER.  Perfect.  But let’s not have anyone go away mad.  How about a turkey sandwich and a Sprite on your way out the door?

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