THE “BAG LADY” IN THE E.R.
To some degree, we all have the “Bag Lady” mentality.
It is simply the thought that the future might be mean and we had better keep something that we would normally throw away in case “We might need it someday.”
Women, because they must care for children, have this thought more frequently than men.
In its extreme form, we have the scene of a little old lady, pushing a shopping carriage in the street, with an overflowing containment of useless and old: rags, bottles and newspapers and other garbage. The lady is always depicted as badly dressed with disheveled hair and wearing a look of worry and foreboding on her wrinkled face.
These ladies are brought into the Emergency Department of city hospitals, by police or concerned citizens who fear for the lady’s well being.
“We need to help this lady!” is the usual complaint. “She’s going to get hurt or somebody will hurt her.”
As an Emergency Department physician I commiserated with the well doer and to myself I anguished: “Oh my God, another Bag Lady. Here come the administration, psychiatry and the police department. And, if I screw up, I’ll get sued and my picture will be in the newspaper: “Doctor sends old lady out of hospital and she is killed by a car!””
All my ducks have to be in line and every department of the hospital has to share in this ordeal.
IS SHE HEALTHY OR SICK?
A determination of health and well being is obligatory for any person setting foot in an Emergency Department. God forbid you sew up a tiny laceration on the forearm and the patient leaves and has a heart attack!
You need to get an accurate and verifiable History. The old lady’s history is worthless.
“Where do you live?”
“Over there…”
“Over WHERE?”
“THERE!”
That won’t work. Somebody has to search through all the rags and layers of clothing and find some form of ID. Your favorite nurse will do that, but she will make you pay for it afterwards, with hours off and boxes of chocolate. Maybe even flowers for her birthday.
There is always a Social Security card or check amidst the old clothing. If not, there are bills or letters addressed to Mrs. “X” and, hopefully a telephone number to call for further identification. If not, it’s the police department and their uncanny ability to identify anyone who lives in the city.
After that, it is a physical examination to determine the status of her health.
WHAT’S UNDER ALL THAT CLOTHING?
Once all the old rags are removed we find a normal old body slightly soiled. She looks like any other patient in a hospital gown.
Her vital signs (blood pressure, pulse, respirations and temperature) are taken and recorded. Vital Signs are the major clues for impending or chronic disease.
An abnormally high blood pressure may mean heart disease or an impeding stroke. A fast pulse might mean anemia or a weak heart. Fast respirations could mean lung disease. And, a high temperature is an infection unless proven otherwise. Any abnormality in the Vital Signs must be explained!
After the Vital Signs an examination of the skin for scars is essential. Surgical scars are easy to recognize. The gall bladder, heart, lungs, pelvis and neck all have their distinctive areas where surgeons have cut the skin to insert laparoscopic instruments or simply open layers of tissue to remove or repair an organ.
The colour of the skin is a major clue to underlying disease. Bluish skin is a sign of heart disease. Pale skin means blood loss. Red skin means inflammation. The rainbow of colours is a clue to the health of the patient.
Touching the skin for a clue to its temperature is next. If the skin is hot, or moist or cool or cold, gives a well trained mind an understanding of what is happening inside the body.
Now, the fingers start pushing. “Does that hurt?” If it does, not good! Could be an inflamed or infected organ under those fingers. Could be a mass that should not be there. Could be gas or liquids where no gas or liquids are normally present.
Then the stethoscope. “Take a deep breath, please.” “What did I hear in the Right Middle Lobe? Why can’t she take a DEEP breath? Oh God, is that a breath or a bubble?”
All the arteries must be listened to for perhaps that fleeting “Bruit” or squishing sound that could mark an abrupt widening of the artery.
The belly is normally full of moving gas and that gas makes peculiar sounds that are almost rhythmic in sequence.
If there are no sounds, you have a major problem. A silent abdomen is trouble, because normally the intestines keep pushing their liquid contents towards the rectum. A silent belly could mean “Peritonitis” which no one wants to have.
When the listening or “Auscultation” is over some docs still might “Per cuss” or tap their flat fingers with their bent fingers. As they tap they listen for the response: Dull? Drum sounding? High pitched?
Each part of the body has an understructure that reflects sound in a unique manner. Unfortunately, percussion has gone the way of the railroad train. Most docs omit it as most people take a jet.
IS SHE CRAZY?
Now comes the hard part. We know her behavior is abnormal, but is she Demented or Crazy? If she is, she’ll have to go into a special living facility. If she is not, she may just go back “home” with the assistance of a Social Worker.
Determining her mental status makes most docs crazy. We know in advance that she will lie and intentionally forget such worthless facts as her name, her age and her marital status.
She knows we may want to lock her up and she will give us a run for the money. Fortunately, we have some form of ID and we already know her name and address.
But “Mental Status” is another ball game. Even experienced well trained psychiatrists lose their cool when they try to determine whether a patient is demented, coy or simply forgetting things normally for their age.
The importance of Mental Status cannot be overstressed. If a patient is demented, suddenly all the legal parameters of every level of government in the U.S.A. are brought into play. The Federal Government, the State Government, and the Local Government must all be involved. After all, a demented person is suddenly a citizen who is not accountable for his or her own actions. She is a living human who has been designated: “INCOMPETENT!”
If you are legally “Incompetent” you can do anything: “Rob a bank. Shoot a police officer or even Win a Lottery” with no consequences. Neither good nor bad. After all, if you are incompetent you legally do not know what you are doing. “We’ll take that five million dollars that you just won! We know what to do with it. You don’t!”
We can easily see we need a Judge and two lawyers to handle a patient that has been medically declared: “Demented.” Any doc who has been down the road will automatically hesitate or even refuse to make a diagnosis of “Demented.”
Once that term is written on the chart it will mean hours testifying before a judge, and if there is money involved, perhaps months of arguing with lawyers and psychiatrists.
Remember, you don’t know whether this apparently poor, old lady may have millions in a bank somewhere, successfully hiding those millions from her greedy relatives.
The best way to handle a diagnosis of “Demented” is to declare that you are “Undecided” and must consult with an objective psychiatrist. Psychiatrists make a large part of their living making such medico-legal decisions.
HOW TO WRAP UP THE “BAG LADY?”
By now, your partner is screaming at you for help with his five patients that include a dislocated right shoulder, two cases of bronchitis a nose bleed and an allergic reaction. “I’ve got to get his lady out of here!” ‘They’re beginning to pile up.”
When in doubt or when in trouble, call for help. “Call the Shrink!” you tell the nurse. “I’ve got a case too difficult to handle.” The “Shrinks” always come in because “Bag Ladies” are part of their bread and butter.
“In the meantime giver a good breakfast! She looks hungry.” The Bag Lady smiles. She’s not demented…
