20 phone calls later, I got help for my patient

When no one else takes responsibility, how far must the doctor go?

By Allan S. Pirnique, MD
Internist/El Dorado, AR

I would rather have played tennis.

Ola Santana first calls on a Tuesday evening. Tearfully, she tells me that she can't handle her 89-year-old husband Albert (I've changed the names), who has become abusive and threatening. I prescribed haloperidol for Albert several months earlier, after he'd started to yell a lot. After talking with Ola, I increase the dosage from 0.5 mg to 1.5 mg every six hours.

But the haloperidol doesn't work. Ola calls me Wednesday morning, again in tears, and says Albert is threatening to kill her and—after she mentioned my name—to kill me, as well. It's clear Albert needs to be admitted to a psychiatric hospital.

I'm not worried that Albert—all 85 pounds of him—will harm his wife. He's been bedridden for months, suffering from malnutrition, obstructive lung disease, strokes, coronary disease, and dementia. Ola is a strong woman who could easily protect herself. But Albert's carrying on is upsetting her, and he does pose a threat to himself: In trying to climb out of bed, he's likely to fall.

Wednesday happens to be the day I don't see patients. Usually, I spend the mornings in my office catching up on my reading, and the afternoons on the tennis courts. So I'm feeling relaxed and tranquil. I have to get Albert the treatment he needs, but I'm sure that won't take much effort.

My first call is to the area's geriatric psychiatry center. When I describe the situation to a social worker and request inpatient treatment, she says they have a bed available. So far, so good.

Next, I call the ambulance company, where I repeat the story. But the clerk who answers the phone doesn't have the authority to order an ambulance for a rowdy person—even one who weighs 85 pounds and can't support his own weight. Someone will call me back.

Fifteen minutes later, someone does call back, and the news isn't good. The ambulance company won't go to a potentially abusive situation. They tell me to call the sheriff's office.

I'm getting a little frustrated now, and I'm looking at my watch. But I decide to see this through. How much longer can it take to get Albert placed?

So I call the sheriff's office and tell my story once again. It's become like a part in a play, and I recite it easily from memory. But I can't get help from them unless I have a court order. I have to call the county prosecuting attorney's office.

I do as I'm told. I explain that neither the ambulance company nor the sheriff's office will pick up Albert without a court order. But no, the prosecutors can't help me, either. I have to call the assistant district attorney's office.

The ADA's office sends me back to the prosecutor's office. At this point, I have a minor temper tantrum, banging my fist against my desk. I've lost my sense of humor.

I'm shuffled again between the ADA and prosecutor's phone lines. Finally, the ADA's office tells me that a complaint must be filed, in person, at the prosecutor's office.

Can I be closing in on my goal? I call the prosecutor's office, where I try to explain that for Ola to come in, she'll have to find someone to stay with Albert. Considering his current behavior, that won't be so easy. "Too bad," is the implied response. "She'll have to do it our way."

It's now noon, a good three hours after I made my first phone call. I'm beginning to worry that I won't reach the tennis courts.

I call Ola and tell her what she has to do. She says she'll do it, but she has to talk to Albert first.

It's starting to sink in just how bizarre this situation is. And I have to admit: The patient has become secondary to the drama that's playing out. I'm sure Albert will somehow be taken care of—though I don't know how, or when. But seeing this through has taken on a life of its own. I'm just going to hang on and keep going. Tennis will have to keep until next week.

When Ola returns my call, she's weeping again. Albert is verbally abusing her, and he won't let her go to the prosecutor's office. She's too upset to go against his wishes, but she can't stand his behavior. She calls 911; someone will be there in 30 minutes, she's told.

Thirty minutes seems too long for an emergency response, so I call 911, hoping to speed up the process. I'm successful: The dispatcher tells me the wait will be 20 minutes. It's now about 4:45 pm.

But there is no ambulance. The next thing I hear is from Ola, at 5:30. She found someone to stay with Albert, went to the prosecutor's office, and signed the complaint. But there's no judge to review it. She's back home, and Albert is still ranting.

So I call the sheriff's office again. This time, I say I'm fearful for Ola to stay in that house all night. The sheriff's aide assures me that they'll handle the situation, and—against common sense and all the evidence—I allow myself to believe him. The night passes with no phone calls, and I assume all is well.

But at 7:30 Thursday morning, Ola reaches me at the hospital, where I'm making rounds. The poor woman is tearful again; Albert is still home, though he's more docile. At last, the police have arrived. They're ready to take Albert to the third floor of the courthouse, where the judge will meet with him. But they ask me whether I think he can make the trip. He must look so bad that they're worried he'll die on the way.

I tell the police to bring Albert to the ED by ambulance so I can examine him. Apparently, that precious court order wasn't needed for this trip.

While I'm waiting for Albert, I call the geriatric facility and confirm that the bed is still available. Then I call my office to say I'll be late.

When he arrives at the ED with Ola, Albert is extremely docile. Aside from a little dehydration, his blood chemistry shows no significant change or acute problem that would prevent him from being a psychiatric inpatient. I tell him he's sick and needs to be in the hospital. Reluctantly, he agrees. Everything is now in place—almost.

We have the ambulance, we have the police, but neither will take him from the ED to the courthouse without a court order. "We don't have the legal authority," the ambulance driver tells me. I feel exasperated: We're so close—and yet we're facing the same brick wall. But I hold my temper; I figure it's better not to anger the police.

I also figure it's time to take control. With the help of Billy, the hospital transport worker, I get Albert into Ola's car, and we all set out for the courthouse. Am I worried about the legalities? I don't care; there's no other way to get this done.

At 10:35 am, the judge signs the court order. Within minutes, an ambulance arrives to take Albert to the geriatric psychiatry center.

After two weeks of treatment, Albert has improved enough to return home. The separation helps both husband and wife, and I think Ola subsequently uses his hospitalization as a club: "Albert, if you don't quiet down, you'll have to go back there." I get no further tearful calls reporting that he's out of control.

With the exception of some hospitalizations for medical problems, Albert stays at home with Ola until his death—from pneumonia—six months later.

Why did I devote so much time to this quest? Though I'd like to think it was purely altruistic, I'm no saint. Once I got into this crazy whirlpool, something flipped in my brain, and I just felt I couldn't stop until I'd seen events come to their rightful conclusion.

I learned two things: We need a more expeditious way to take care of folks who should be in the hospital but don't want to go. And I need to learn more about the legal system. There has to be a way to short-circuit a process in which no one in authority is willing to take control.

 

Allan Pirnique. 20 phone calls later, I got help for my patient. Medical Economics 2002;1:90.