Mentally Ill AIDS Patient’s Case Shows System Failure

A mental patient, infected with the AIDS virus and bleeding from his arms and legs, spent last weekend wandering through central Orange County after he was turned away from a state mental hospital and then refused readmission to a private hospital in Anaheim.

The 37-year-old man, who has been declared a ward of Orange County, reappeared at his guardian’s office in Santa Ana on Oct. 26 and is now hospitalized at UC Irvine Medical Center in Orange.

Orange County health officials who related the story said it began Oct. 23 when Western Medical Center-Anaheim tried to transfer the patient to Metropolitan State Hospital in Norwalk for long-term psychiatric care, and Metropolitan declined to accept him because he was infectious and in need of medical care. Returned to Western Medical, where doctors said he no longer met their standards for admission, the patient walked out a back door when a social worker assigned to watch him went to the bathroom, hospital officials said.

Lack of Facilities

Orange County Public Health Director Dr. L. Rex Ehling said the confusion in this case exemplifies the lack of treatment facilities in the county and throughout the state for AIDS carriers who also have serious medical or mental problems.

Orange County health officials also expressed concern that the state appears to have no coordinated policy for how county, state and private hospitals should care for a psychotic and infectious AIDS carrier with acute medical problems.

“We have gotten . . . little or no policy direction from the state Department of Health,” said Ehling, who as president of the California Conference of Local Health Officers lodged a protest with state health officials last week.

Added Orange County Mental Health Director Timothy P. Mullins: “The problem . . . is there are no places, or at least only a few places, in the entire United States that are equipped to handle the medical and psychiatric needs of the severely mentally ill person who has AIDS or AIDS related complex. . . . Programs for those are not currently in place.”

‘Much Larger Problem’

Dr. Alexander Kelter, a deputy director in the California Department of Health Services, said he did not know if any policy changes were necessary. “To me this is a microcosm of a much larger problem that doesn’t have anything to do with” the AIDS virus, he said, “but with (psychiatric patients) who are medically acute or sub-acute and nobody wants them.”

But Orange County officials said they believed that the man’s AIDS infection was an important factor.

Hospital and health officials declined to name the patient because, as a ward of the county, his privacy is protected by law. But they agreed to provide details of the case because of the dilemma it posed and the ethical issues involved.

Their problems began July 7 when police picked up a psychotic transient and brought him to Western Medical Center-Anaheim, officials at the 248-bed, nonprofit hospital said. For 17 days, he was acutely psychotic, hospital officials said.

After that, the man still was mentally ill but was no longer acute, they said, and because his diagnosis had changed, Medicare no longer automatically covered his $552-a-day costs for psychiatric nursing in an isolation room. So the private hospital began looking for another placement.

For three months--and with increasing desperation--Western Medical officials and the patient’s county conservator looked for a long-term, locked psychiatric bed among the overloaded mental health institutions in Los Angeles, Riverside and Orange counties.

But because of his psychosis and because he carried the AIDS virus, no one would take him, said Sharon Gerdes, who is in charge of discharging patients at Western Medical.

Although the man has not developed a full case of the deadly acquired immune deficiency syndrome, he could infect others if his blood came in contact with theirs, health officials said. And because of his psychosis, Gerdes said, the patient for 20 years has scratched himself until his arms and legs bled. Then, three weeks ago, 750-bed Metropolitan State Hospital in Norwalk agreed to accept him when its next bed became available, Gerdes said.

Patient Discharged

On Friday, Oct. 23, the bed came open. At about noon that day, Western Medical officials said, they discharged the patient and put him in an ambulance for Norwalk.

But during the ambulance ride, the patient became agitated, scratching his arms and legs until they were raw and bleeding, Orange County AIDS coordinator Penny Weismuller said.

When he arrived at Metropolitan at 1:50 p.m., admissions staff immediately noticed the “weeping sores” on his legs, Metropolitan Executive Director Dr. Bill Silva said. Greeted by a bleeding, AIDS-positive patient who appeared both “medically unstable” and infectious, Metropolitan could not admit him, Silva said.

Western Medical attorney Patrick Moore contended Friday that Metropolitan had “welshed, if you will, on their agreement” to take the man. “His condition had been fully disclosed to them,” Moore said.

Silva called that account “totally inaccurate.”

California’s state mental hospitals do accept patients with the AIDS virus and now have about 30, at least 12 at Metropolitan, said Dean Owen, a spokesman for the California Department of Mental Health.

‘Medically Unstable’

But Metropolitan cannot accept patients who are sick with AIDS or anything else that makes them “medically unstable,” Owen and Silva said. State law prohibits hospitals from discriminating against AIDS patients, but if a hospital lacks proper treatment facilities for an ill AIDS patient, it may reject the patient, state mental health officials said.

All referring hospitals are well aware of Metropolitan’s medical criteria for accepting a patient, Silva said. There is no medical ward or isolation room at Metropolitan. “If he had leprosy, he wouldn’t be admitted,” Silva said.

By mid-afternoon that Friday, Silva and his admissions staff notified Western Medical that their patient would be returned to them, and at 3:50 p.m., put him back in the ambulance to Anaheim.

About 5 p.m. Oct. 23, the ambulance returned the patient to the rear lobby of Western Medical, Gerdes said.

Not Appropriate Candidate

Doctors there reexamined him, found him mentally ill and in need of long-term placement but not acutely psychotic--so he was no longer an appropriate candidate for their hospital, Moore said.

At that point, “he’s really no one’s patient,” Moore said. “We couldn’t admit him” because without a physician’s order, “we legally cannot take that patient back. We’d be subject to liability for in essence involuntarily detaining the patient.”

Late Oct. 23, Gerdes said she telephoned officials from the county conservator’s office to ask where the patient should go, but got little help.

Citing confidentiality laws, officials from the county conservator’s office declined all comment last week.

Meanwhile, Western Medical officials assigned one of their social workers to sit with the patient while they figured out what to do with him. All his clothes and other belongings were with him in the small room, Gerdes said. One of the ambulance drivers gave the patient a quarter and the social worker fed him dinner, Western Medical officials said.

‘Walked Out the Door’

About 7:30 p.m., “we were trying to get some guidance from the patient conservator and the patient walked out the door while the social worker went to the toilet,” hospital attorney Moore said.

What the patient did next is unclear. There are reports that he went to a local park or a mission over the weekend as he wandered the 10 miles from Anaheim to Santa Ana.

In the morning of Oct. 26, he showed up at his conservator’s office in Santa Ana, Gerdes said. From there, he was taken to an emergency mental health treatment facility in Santa Ana, then transferred to a medical ward at UCI Medical Center.

Nurses wear gloves when they dress his sores or start an IV, said Pearl Jemison-Smith, infection control nurse-epidemiologist at UCI Medical Center and chairwoman of an Orange County advisory group on AIDS called ACTION. The patient is in a room by himself, not because of his AIDS virus, but because of his psychosis, she said.

Casting Blame

Metropolitan has agreed to accept him for treatment once his sores are healed in the next week or two, Silva said.

To Metropolitan, the fault lies with Western Medical.

“The issue is why we didn’t take the guy,” Silva said--who contended that there was a good reason: “He’s in a position where he’s got a communicable disease. And all we’re asking (the referring hospital) is, ‘Please, reevaluate or treat the patient--and once they’re better, send them back to us.’ ”

But Western Medical’s Gerdes expressed outrage that Metropolitan could not care for the patient’s sores. “If they just wrap his legs, then he doesn’t scratch his legs. They said, ‘We don’t have nurses up here who can wrap patients’ legs.’ ”

To Kelter, deputy director for the state health department, both hospitals appeared to share in the blame. “It seems to me every institution has an obligation to hospitalize individuals who need to be hospitalized (whether for medical or psychiatric reasons). . . . It almost sounds like an Alphonse-Gaston routine--’After you. . . .’ ”