Question

The Patient’s Experience: What Were They Thinking? – Case for Chapter 4

Sheila K. McGinnis

Thanksgiving weekend. Tanya Martinez is looking forward to a busy holiday weekend entertaining her extended family. Tanya, 29, is a busy stay-at-home mom. She has a degree in Business Administration and recently worked in marketing for a major insurance company in the city. Married nearly 8 years ago, Tanya and her husband Alex, 29, have two children. Tanya quit working several years ago to raise their two children, 4-year-old Randy and 2-year-old Samantha. The Martinezes, a multiracial couple, lived in a large city in the Northwest, where Alex works as a skilled construction carpenter on high-rise commercial building projects.

Tanya, Alex, and the kids celebrated the holiday with Tanya’s mom Deidra, a city engineer; dad Michael, a college professor; her brother, a computer engineer; and her sister-in-law, a nurse practitioner. On Friday, Tanya felt some nausea and intestinal discomfort, which she assumed was due to the Thanksgiving festivities. While Tanya was typically active and athletic, she had to skip her usual long-distance run. By Saturday, her condition had quickly worsened. She was weak, vomiting with periodic abdominal pain, and using cold compresses for a high fever.

With Tanya running a 103^o fever Sunday, Alex stayed home with Randy and Samantha, while her parents Deidra and Michael took her to Urgent Care at a nearby full-service medical center. There she was quickly sent to the Emergency Department of the 400+ bed, Level 2 Trauma Center. Various lab tests and a CT scan showed an elevated white blood cell count, but no conclusive findings regarding her non-specific intestinal discomfort. So, after rounds of antibiotics and fluids for dehydration, Tanya was sent home without any prescriptions or further instructions.

Tanya’s condition did not improve by Tuesday, and she was still experiencing a high fever plus nausea, bloating, and abdominal pain. The family brought Tanya back to Urgent Care, where she was sent to the Emergency Department again, and then referred to the main hospital for observation care. Observation care is a hospital outpatient category (even though patients stay overnight). It is controversial because it blurs the lines between outpatient and inpatient care, which often increases the patient’s financial liability (due to larger co-pays). It can also compromise clinical care delivery due to poorer coordination of care during observation stays (Hagland, 2018; Society of Hospital Medicine, 2017).

In the observation care ward, Tanya was seen by several hospitalists who each interacted with her for different purposes and with different questions. They conducted a variety of additional blood draws and lab tests to assess intestinal illnesses such as Crohn’s disease, inflammatory bowel conditions, or possible intestinal blockage. While observation care is intended to take 24 hours, or 48 hours maximum, in practice it sometimes exceeds 48 hours (Society of Hospital Medicine, 2017). Tanya ended up in observation care for 5 days.

Observation ward rooms are shared, and during Tanya’s stay, three different female roommates entered observation care and were admitted to inpatient care shortly thereafter. Tanya’s first roommate did not permit Tanya’s husband Alex to stay overnight with Tanya, so her mother stayed with her each night. Alex, their children, and family were frequent visitors during the 5 days.

One evening when both parents Deidra and Michael were visiting Tanya, they noted two uniformed city police officers in the corridor talking to the in-charge nurse. The pair of officers soon entered Tanya’s room unannounced saying “We have to check your belongings,” without offering any explanation. Tanya and her parents complied but were unclear about what was happening. When one officer asked, “Does she have a history of drug abuse?” Deidra exploded, saying “What are you doing here? Leave right now!” The officer explained “We’ve had calls and a report there have been a lot of visitors and possible illegal drug activities here.” Next, the in-charge nurse burst into the room stating, “It’s a mistake, it’s not this room, it’s another room!” The officers were quickly redirected to search the nearby room occupied by a well-tattooed white male.

Frustrated by days with no clear diagnosis or treatment plan and angered by the allegation his daughter was using drugs, Michael demanded “I want to see the nursing supervisor now or we are leaving this hospital and will sue you!” When the RN supervisor arrived, Michael confronted him “Why did you call the cops on my daughter?” The supervisor wanted to check on what happened and scheduled a meeting for the next day after tempers had cooled.

During a tense meeting with the RN supervisor the next day, her parents sought to transfer Tanya to a different hospital and leave “Against Medical Advice” (AMA). Informed that insurance might not cover an AMA transfer, and that another hospital might not accept an AMA, they “felt like hostages, with no options.” Unwilling to take the risk, the parents compromised that the hospital could transfer Tanya to the medical floor on in-patient status with a private room.

Michael and Deidra also confronted the floor nurses, asking “Why did you send the police to Tanya’s room?” The nurses explained that “somebody had called the cops,” leaving the nurses to guess which patient it might be. A junior nurse admitted she had pointed the police towards Tanya’s room. Even Tanya’s observation ward roommate, who was present when the police arrived, said their treatment from the nurses and officers was inappropriate. The hospital’s security chief apologized and said he “would look into” the incident with the police.

Tanya spent another week as an inpatient on the medical floor. At the time of transfer to inpatient status, she was generally stable, though very weak, and showed few signs of improvement. She was still nauseous, with abdominal distention and cramping, and little bowel activity. The family hoped Tanya’s attentive new physician, Dr. Johnson, would finally get a clear diagnosis and treatment plan. Dr. Johnson arranged for endoscopy and requested other consults, though staff resisted performing a second CT scan (after two previous ones in the ED), saying “she should get better.” Finally, 4 days later, before going off rotation, Dr. Johnson’s written medical report called for a surgical consultation, stipulating that if the hospital could not provide answers and appropriate treatment the patient would need to be transferred to University Hospitals for additional evaluation and care.

At last the third CT scan clearly showed an intestinal ileus—a potentially dangerous stoppage of the normal intestinal contractions that move food through the intestines. While an ileus is commonly a complication of abdominal surgery, Tanya had no history of surgery or medical conditions that lead to an ileus, and prior to her sudden hospitalization had been very healthy and fit. After surgeons drained accumulated fluids and matter from her lower abdomen, they put her on antibiotics, and released her from hospital the next day—after 2 weeks in the hospital. Tanya gradually recovered at home, though it took several months to regain her strength and eventually return to her active lifestyle.

Deidra and Michael filed a complaint on Tanya’s behalf shortly after she was released from hospital. They identified the following substandard practices:

• ■   Abusive encounter: Patient was accused by uniformed police of using drugs without reasonable cause. This incident also raised the question of whether Tanya and her husband came under suspicion because Alex is of Latino/Native American descent.

• ■   Negligence that compromised quality of care: Patient was assigned to observation care for 5 days without clear diagnosis and treatment; patient was admitted on in-patient basis for 5 days and staff resisted taking further action to refine the diagnosis and treat appropriately. The resulting delayed confirmation of an ileus further weakened Tanya and prolonged her time to full recovery months later.

• ■   Observation Notice Requirement: Patient was assigned to and maintained on observation status without sufficient diagnostic efforts, and without explanation of its clinical and financial implications.

The hospital completed its internal review without interviewing Tanya, her family members, or her roommate. While acknowledging the grievance, the hospital’s report concluded Tanya’s care was appropriate.

QUESTIONS

1. What automatic thinking, cognitive biases, and stereotypes may be affecting how each of the actors sees this situation? Include as many as you can think of.

2. What stereotypes or biases might hospital staff hold about a potential drug user?

Answer 1

1.In this case, The patient(Tanya) experiences automatic thinking because of her health condition. Anxiety and depression of a patient to delay the process of recovery. Fortune telling is the suitable term to describe the patient's thinking. Negative automatic thinking also comes under the patient negative thinking about health. Cognitive biases also involved in the way of patient thinking . Optimistic cognitive biases is the positive thinking of the patient. It can improves the patient condition.

Stereotype is an idea about the group of a people that can gives an information. Tanya's parent decision makes Tanya to get better from the severe illness. This incidence again gives an positive cognitive biases.

2.Stereotype explains about the tag and belief in a certain group of people. The hospital junior staff should thoroughly know about the drug abuser .But the junior staff don't know about the information of drug abuser. This incidence explains about the stereotype of the hospital staffs.