Sunrise, Sunset (Swiftly Flow the Days...)

Wow, time flies! I didn't realize how long it'd been since my last dispatch, but time has a way of getting away from us in The Nuthatch.

You probably wouldn't have guessed this, but the idea of time looms large in our work here. We have daily rounds with psychiatry, nursing and social work to discuss the progress of every patient in our care. How long have they been here? When was the last med change? How many days since the last bout of head-banging? How many more hours of unit restriction? And, of course: How many days of insurance coverage left?

Since most of my patients have chronic illnesses, most are insured by Medicaid and/or Medicare. Some may have 30, 60 or even 90 covered hospital days. That might seem like a lot of time, and I suppose it is, but nevertheless it's sometimes not enough.

Gloria (the manic lady that Andy from One Small Step For Man played a game of cards with) got steadily better for a couple of weeks. But whenever I've talked to Gloria about her son, she says he's great, he's fine, she can manage him just fine. She doesn't know why her family keeps calling me with concerns; she doesn't know why they want to send him to family out of state; she doesn't know why her mother would say that she beats him. They're lying. They're the crazy ones. No, you can't talk to them; it's between us.

The more she's getting herself pulled together, the more we can challenge her to be realistic and candid about her son. Each time she gets pushed a litte, she falls apart a little. Then she pulls it together again and we start over. This last time, though, she fell apart a lot. She's back to being intrusive and illogical, belligerent, and laughing to herself. She's gotten a blank hospital wristband and has written "Chai" on it. I asked her what that meant and she said, "You know," holding up the wristband for me to see, "Chai, chai, chai. You know." She pronounces it like the tea and not like a lyric from Fiddler (she's Hispanic, besides), and I'm just baffled. She's back to writing "Chai" on her artwork -- she colors relentlessly -- as well as on that of others and on random items she finds on the unit (like the sign on the nursing office door). Her functional tests show that right now she doesn't have the judgement to avoid common hazards and so needs to be supervised 24/7.

But the worst news? She's out of covered days early next week. So on Monday, I'll face the wrath of utilization review. This'll be one of those heated, but ultimately pointless discussions with The Powers That Be that they have just to be able to say they addressed the issue with the offending party. Think scolding from a first-grade teacher. It won't actually change anything, and it certainly won't get the patient out the door any faster; it's just one of those exercises we go through to feel like we're doing all we can. Kind of like invoking an invented mantra time and time again.