When medical protocol meets family concerns

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An excerpt from 2060.

Willis murmured, “Not again.” He approached his mother, who was lying in bed with an uneaten tray of food on the bedside table. A stream of drool collected on her gown as she slumped to the right. “Mom.” Willis gently shook her, and she attempted to open her eyes, but fell back into a stupor. Willis said louder, “Mom, wake up.” She opened her eyes again, but moved nothing else. He grabbed her shoulders and tried to straighten her in the bed. Her head stayed upright for a moment, then slumped straight down. “Mom, it’s Willis.” She tried to lift her head again, briefly made eye contact, but only produced garbled speech. The personal e-assistant in the room didn’t recognize Willis’s voice. Willis kept a hand on her shoulder and reached over to press the help button on her bed control device.

“I need some help in here. Adriana Smith is hypercalcemic again.” No answer. He repeated the message.

A few moments later, a voice said, “May I help you?”

“Adriana Smith is hypercalcemic again and needs some fluids.”


Willis realized he was talking to the secretary with no medical training. “Hypercalcemia. It means her calcium levels are too high.”

“I’ll tell your nurse.”

A few minutes later, an overweight woman in orthopedic shoes ambled into the room. “What seems to be the problem?”

Willis was sure his face belied his inner frustrations, but at the moment, he didn’t care what this woman thought of him. “Where is Joanna? She knows my mother and knows what to do.”

“I don’t know about any Joanna, sir. I’m just covering this facility tonight and tomorrow night. Now, why did you call?”

Out of the corner of his eye, he could see the uneaten tray of food, the drool spot on her gown, and the shoulders of a 67-year-old woman he actively had to re-position to keep her from slumping down into a crumpled ball of human tissue. What do you mean, ‘Why did you call?’ There is nothing normal in this picture. He said, “She’s hypercalcemic again. This is what she looks like when it happens.”

“I wasn’t told anything about hypercalcemia at shift change.”

Willis let out a huff, took another breath and said, “She has kidney cancer that has spread to her bones. That’s why her calcium level gets so high.”

The nurse said, “All I see recorded in the nurses’ notes from the past few shifts is nausea, and they gave her medicine for it.”

“Exactly. That’s what happens. She gets nauseous, doesn’t eat as much, she gets dehydrated, and her calcium level skyrockets. All she needs is a couple of bags of IV fluid and she’ll wake up again. I’ve seen this a dozen times.”

“I need to call the doctor.”

“No, you don’t.” The nurse glared at Willis’s infringement on her job, implicitly threatening her nursing license. He quickly added, “Joanna sets up the IV of normal saline and runs it in full blast. Usually, two bags do the trick.”

“That’s a violation of protocol.” The nurse turned and walked towards the nursing station and called the on-call physician. Willis harrumphed in disgust and just stared at his mother. He knew he would have to prop her up a while longer.

Ten minutes later, the nurse walked back into the room. “The doctor ordered her sent to the ER for further evaluation.”

“No, no, no,” yelled Willis. “That’s ridiculous. There is no reason for her to make yet another trip to the ER.”

“Sir, she is clearly not doing well and needs a proper evaluation.”

“Get me the Team Lead.”

The nurse rolled her eyes and left the room. A few minutes later, an older woman walked in.

“I hear you are upset that we called an ambulance.”

“You’re damn right I’m upset.” Willis recounted his version of what had transpired and added, “Here’s what will happen. After she gets the IV fluid for a few hours, she’ll become more alert, and then she’ll freak out because she won’t recognize her surroundings. If I’m not there to calm her down, they will give her tons of sedatives and we’re right back where we started.”

The nurse and Team Lead stared impassively at Willis, offering no reaction. He continued, “But if she gets the IV fluid here, she wakes up in familiar surroundings, she won’t freak out, and all is well. And then I don’t have to spend hours in an ER exhausting myself, just so I can look like I was out all night partying when I show up to my new forty job I’ve only had for a few months.”

The Team Lead said, “Sir, we are following protocol and so is our on-call physician.”

“Then your protocol sucks.” Willis could hear an ambulance in the distance.

The Team Lead stiffened her back. “I will have you know that IntegraHealth has created the highest quality data-driven protocols in the industry. Anything less is not acceptable on my watch.”

Willis stared at her for a moment, still propping up his mother, realizing that this company woman, this fellow employee, would not move easily off of her position. “Where is Joanna? Do you know?”

“I believe she was let go, not surprisingly, for not following policies and procedures.”

The sound of the ambulance grew louder and a minute later, paramedics walked into the room. Willis said, “I am her medical power of attorney, and I refuse to let her go to the ER.”

The Team Lead looked at the shift nurse, who nodded that yes, the record showed he was his mother’s medical power of attorney. The Team Lead walked over to the computer and clicked more buttons. She said, “I do not see an Advance Directive on file. She is a full code.”

“That’s right.”

“Well then, we, and by that I mean your mother, is in a bit of a pickle. If you don’t let these fine paramedics take her to the hospital, then that will trigger a care plan review by our general counsel’s office. They will undoubtedly make a finding of significant family neglect, which will result in her being transferred to another facility.”

“You can’t do that.”

The Team Lead smiled. “Oh, yes I can. And you can be damned sure that I will do everything I can to transfer her out of here. I will not let your poor decisions taint out excellent quality score.”

The paramedics stood there waiting for someone to break. The roommate groaned louder, agitated by the people crowding next to her bed and shouting in her room.

Willis knew he was trapped. He had applied for his mother to live here ever since the cancerous lesion in her lower spinal column eroded through enough bone that the vertebrae collapsed, which left her paralyzed. When the Team Lead said, “another facility,” he knew exactly what she threatened. A substandard nursing home full of Medicaid patients.

Willis backed away from the bed and his mother slumped over again. He made a slight movement of his head to the paramedics. They approached the bed and loaded her up.

The Team Lead said, “That’s a wise decision Mr. Smith.”

Richard Young is a family physician and author of 2060.


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