After 2012 When They Can’t Use the Geezer No More

Here’s a fantasy for you, set in the post-2012 anomaly in which, rather than the end of the world occurring as predicted by the Mayan calendar, an abrupt acceleration of the evolution in thinking occurred at all levels of society, especially human medicine.

On work rounds the medical student had just finished presenting the History and Physical about an elderly male patient admitted overnight from a nursing home. It was a routine case of delirium and the first year resident struggled to avoid jumping in to wrap up the assessment and plan. The patient had visual hallucinations and agitation in the emergency room prior to being brought to the floor.

Medical Student: Mr. X is a 78-year-old retired electric vehicle recharging station worker with a premorbid history of dementia admitted with an acute change in mental status marked by disruption in attentive focus, grossly disorganized thinking, and fluctuations in the level of consciousness. Lab values are not stone cold normal and indicate a urinary tract infection.

Attending Physician: OK, call psych.

First Year Resident: Well, Dr. Proctoscopalopidus, the psychiatry consultation service wouldn’t have much to offer. Most routine cases of delirium are handled by the primary team nowadays.

Attending Physician: Since when?

Nurse Manager (interrupting): We have Confusion Assessment Method (CAM) assessments overnight clearly showing Mr. X is delirious. Since we started using the iPad8000 a few generations ago, funded by the  Inouye World Without Delirium Grant (Dr. Sharon Inouye died so young, only 800 years old!), we’ve made delirium detection routine.

Attending Physician: OK, fine; let’s get some Haldol on board.

Clinical Pharmacist: Well, Dr. P, Mr. X’s behavior has not been problematic…

Senior Medicine Resident: And his cardiac conduction is pretty prolonged, in excess of 500 milliseconds. I’d be pretty concerned about torsades de pointe in this elderly gentleman with a previous history of coronary artery disease.

Medical Student: I notice he was placed in restraints for some reason.

Nurse Manager: I’ve already taken care of that mistake; she was a student nurse and was marginal on her clinical practicum exam. I sent her to the Annex.

The Annex

Attending Physician: Oh well,  as long as he has a foley in…

Nurse Manager: Oh we’ve been able to take care of him without that.

Medical Student: I saw a foley catheter in a museum once. Don’t they worsen delirium?

Attending Physician: Anyway, I still think we need the psych people to help out with the PTSD issues.

First Year Resident: Dr. P, I found only one paper in the Public Library of Science about PTSD in delirium. It was a case report that Dr. Amos finally got published after he sued the now defunct journal for taking twenty years to get the paper through its editing process.

Medical Student: So when is that statue of Dr. Amos going to be erected in the Quad?

Senior Medicine Resident: Sometime in the next millennium, if the asteroid doesn’t destroy the planet first, and if Congress does something about the PlayDoh shortage.

Attending Physician: Mr. Spock, you green-blooded sorry excuse for a Science Officer, we…need your help…we need Hydroxyzine or Alprazolam…to get Mr X…under…control.

Nurse Manager: Jim; he’s dead Jim!

Medical Student slapping Dr. P in the face: Snap out of it, sir!

Clinical Pharmacist: At our interdisciplinary case conference yesterday, we decided to flush all of our supplies of those and other deliriogenic drugs, the ones that are left in the vault anyway that haven’t turned to dust by now.

Attending Physician: We must move quickly and get Mr. X on the wait list for transfer to the Medical Psychiatry Unit. After all, that’s the best place to manage delirium in the hospital.

Nurse Manager: Mr. X has not ever tried to get away from the unit, he’s not violent, and most of the shift nurses describe him as “pleasantly confused.” I’m not sure what would be done differently for him on the Med-Psych Unit. In fact, many patients with dementia tend to get behaviorally worse the more times you transfer them within the hospital. We’re good here.

Medical Student: I wonder if we could start talking about treating his underlying infection, which is probably the cause of his delirium.

Attending Physician: I was getting to that. Let’s start Vancomycin.

First Year Resident: Should we wait for the antibiotic sensitivity panel, Dr. P?

Attending Physician: What do the psychiatric consultants say? I thought there was a new combination drug, Haloperibactrivaliumazolin?

Clinical Pharmacist: It’s not on formulary.

Nurse Manager: Mr. X seems to have trouble hearing, should we get him a pocket talker?

Attending Physician: What?

Medical Student: I’ll check his ears for impacted cerumen.

Attending Physician: What?

First Year Resident: Mr. X had kind of restless night; I was wondering…

Attending Physician: Right, Ambien with just a touch of Oxycontin in an Old-Fashioned, shaken not stirred.

First Year Resident: I was going to suggest warm milk.

Attending Physician: I said warm bourbon.

Medical Student: I’ll call Mr. X’s family and let them know what we’re doing for him.

Attending Physician: Thanks so much, and while you’re at it, call Mr. X’s local psychiatrist, since that’s what a book I read once recommended and nobody seems keen on calling our own psychiatric consultants.

Medical Student: Well, Mr. X doesn’t have a psychiatric history, Dr. P. In fact, many patients who get delirious in the hospital don’t have a previous history of psychiatric treatment.

Sound of a pager going off, then,

Nurse Manager: Dr. P, you’re wanted at The Annex.

%d bloggers like this: