Hold on Tight

Alternate title: Why Social Work Will Take You on the Ride of Your Life...Every Day

I mentioned that Friday was a crazy day, right?  There are many reasons why a day in the life of a hospital social worker can be crazy.  But Friday was a particularly special kind of crazy. 

Not only did I have multiple discharges to arrange (which means making referrals, finding an accepting facility, getting insurance authorization, setting up transportation, and communicating all of the above to the patient and family), but I also had a patient who refused to do anything without my "permission" (more on that in a minute), and a psych placement.  With out-of-area insurance.  Who was refusing to go to inpatient treatment, despite the fact that she was under involuntary committment and therefore legally couldn't refuse.  It's unnerving to have to tell someone, "I'm sorry, but, um, tough shit, you're going to get on that ambulance stretcher and go to treatment."  Legal committment or not, it's not pleasant to force someone into treatment.  We actually had to call security at one point because she threatened to walk out.  I had to stand there and have a discussion with her about the fact that she was being committed against her will and she had absolutely no choice in the matter.  Not. Fun.

But that's not the part that made my day so roller-coaster-y.  (Yep that's totally a word).  I had another patient who, when he first came into the hospital, you could not have a rational conversation with him.  He was delusional and paranoid.  I know, it sounds like I work on a psych floor, doesn't it?  I promise, I don't.  He was delusional due to a medication toxicity - he'd accidentally/unknowingly overdosed on one of his home medications, and it caused him to go a little wacky for a bit.  Once his toxicity level came down, he calmed down and was able to have a real, meaningful, purposeful conversation. 

This patient had been (through his perception) abused by the system his entire life.  He was distrusting of everyone in the hospital.  He threw several doctors and nurses out of his room.  The first time I met with him, I had to walk away because he was so abusive.  But somehow, I got through to him and he grew to trust me.  He felt like, for his whole life, he'd been promised things that were never delivered.  I did what I told him I'd do, and I think he felt like he finally had someone on his side.  He needed help at home but refused to sign the paperwork necessary to get the help at home because a) he is illiterate and b) he was afraid they'd take his house (a very common misconception, unfortunately).  Once I explained everything to him, he agreed to have the caseworker come back and to sign the paperwork...only if I was present for the meeting and explained anything he wasn't sure about. 

So I was and he signed everything.  It was kind of a proud moment for me.  As a social worker, it is incredibly fulfilling to know that you gained the trust of a man that so few others could not.  He signed the paperwork.  He agreed to go a nursing facility for rehab ("for one week!"), even though the facility that accepted him was outside the city.  I had everything arranged for him to go on Saturday.  I left work exhausted but feeling like I had done some real social work. 

I came in this morning and received a voicemail from his insurnace company saying that he'd never arrived at the nursing facility.  I called the facility and they told me that they'd received word that he'd left the hospital AMA, meaning Against Medical Advice, before his discharge.  I checked the chart and, indeed, he had signed out AMA. 

I have to admit, I'm a little heartsick over this.  I thought I had done some real work.  I thought I had made progress and made a difference in this man's life.  I thought we had a deal.  The nurse practitioner who was on service the day of his discharge is not here today, nor is the nurse who discharged him, so I can't find out what exactly went down until later in the week.  I ended last week on such a high, and this is a pretty major blow.

In my heart of hearts, I know that I do good in my job.  But things like this make it hard to see the forest for the trees.