Frequent Flier

“Oh wait, I know that guy!”

My senior resident and I were catching up early in the morning, going over all the new patients that came in through the ER overnight.  I looked at the notes scribbled on my patient list: “41M, history of iv drug abuse, presents with fever/chills, WBC elevated, vital signs stable.”

My resident was already looking up his history on the computer, and sure enough, his name pops up a year ago – another admission to the hospital, about a week long.  “Yeah, I remember writing notes on this guy.  Same stuff, IV drug abuser, got an infection from his needles, gave him vanc/zosyn for a few days and he went home.  So it’s gonna be a pretty standard admission.  Fix him up, send him out.  He’ll be back soon anyway.”

“Great,” I say.  It’s never a good thing when your resident knows an incoming patient by name.  Oh, sometimes it’s harmless, a little old lady who comes down the flu every year or two.  But for the most part, people who keep coming back to the hospitals aren’t just suffering from bad luck, they’re doing something else wrong – not taking their medicine, or in this case, taking a bit too much medicine of his own on the side.

When I examine him, he looks barely sick at all – well built, sitting upright on his bed, cheerful and polite.  When I ask him about drug abuse, he admits to shooting up “a little more than is good for me.”  I smile and say “Well…you know that I’m going to say here” at which point he sheepishly grins and says “Yeah, yeah, gotta knock that off, I guess.”  With honor satisfied on both of our parts, I head out and start writing notes.

It’s a pretty uneventful couple of days.  We give him broad-spectrum antibiotics, and a few days later the blood cultures we drew in the ER come back positive for a species that the antibiotics can treat well.  So far so good.  But as the days go on, we notice a strange pattern.  Every few days, he’d spike a fever and have elevated white blood cell counts in the morning, which then quickly subsided by the next day.  At first we chalked this up a glitch in the lab, but by the second time we started getting suspicious. We were blasting him with antibiotics that should easily treat the infection he came in with, so why was he having relapses?

In the end, it was a diligent nurse rather than clever detective work from our side that uncovered the truth.  Overnight, our patient kept requesting pain medications, saying he was unable to sleep and that nothing but opioids helped.   The night intern, playing it safe, gave him a small dose of one of the weaker opioids, Percocet.  The patient said thanks and promptly stepped into the bathroom.  Fifteen minutes later, the nurse got suspicious, tried to open the door, and found that it was locked.  Negotiations ensued.  Eventually, it was revealed that the patient had chewed up his tablet of Percocet and spit it directly into his IV line, in order to get a nice short high rather than a slow release of pain relief.

In the morning, sure enough, he spiked a fever and had an elevated white blood cell count.  We drew blood cultures and found that he had started growing an exotic species of bacteria found only in the human mouth.  The next day, he had a heart murmur that he didn’t have before.  We consulted the cardiologists and as we suspected he had developed endocarditis – an infection of his heart valves – in spite of our antibiotics.  If the antibiotics weren’t going to do the job, he’d need surgery.  As the week went on, the murmur got worse and worse, and he started getting noticeably short of breath as the valve deteriorated further.  Finally, the surgeons said enough was enough, and took him in to get the valve replaced. Throughout these days, he remained unfailingly polite, kept requesting pain medications, and steadfastly denied that The Incident With The Percocet Pill ever happened.

This case was a memorable one, but a large fraction of the patients we saw did come in with conditions that were essentially self-inflicted.  The alcoholic who comes in to sleep it off for three days.  The cocaine abuser who presents with a cardiac arrhythmia from just having used cocaine.  The guy who passes out every time he smokes weed, who came in…after passing out while smoking weed.

But if taking drugs was one route to admission, so was not taking drugs that you should be taking.  Just down the hall from this patient was a woman coming in with an asthma exacerbation, her third admission this year.  And when I asked her what medications she’s been taking, she immediately mentioned that she hadn’t been taking her long-acting inhaler, the very one that is supposed to help prevent these flare-ups.  We’re not talking about forgetting a dose or two, we’re talking about flat-out not filling her prescriptions and not taking them.  When I asked why, I got the answer I always got: “If I don’t feel sick, why take these medications?”  She was happy to take medicines that help immediately solved her problems – she had no problem with taking a short-acting inhaler right when she got short of breath.   But if a drug didn’t give an immediate payoff, like a long-acting inhaler, then she didn’t see a reason to take them.  And multiple admissions to the hospital, and all the eloquence I could muster, couldn’t dissuade her.

Keep in mind, she was an otherwise normal woman, with a respectable job and two kids, and our conversation went fine as I explained the treatment plan while she was in the hospital.  But as soon as the topic turned to those long-acting inhalers, it was like running up against a glass wall: she believed me when I said that not taking them was one of the reasons she kept having to come to the hospital, but couldn’t wrap her mind around why she should take them after getting discharged.

This sort of conversation was mind-boggling when I first came across it.  It’s hard for me to imagine any of my friends intentionally letting a disease get out of hand through neglect – doctors proverbially make bad patients, but not that bad!  But one of the fascinating aspects of medicine is that it exposes you to a true cross-section of the population, and one of the bizarre realities you pick up is that this sort of elementary planning is foreign to a fair number of otherwise unremarkable people.

And health policy statistics agree.  There’s perennial debate about how much we should spend on end-of-life care for the elderly, with one side shouting “death panels!” and another pointing out that the last few days of life gobble up huge quantities of money. But what neither side mentions is that the majority of the high-cost patients are actually what they rather blandly call “non-elderly high spenders.” Take the top 5% of patients who incur the highest healthcare costs, and you’ll find that the majority are under 65.  And for people under 65, the spending is distributed incredibly unequally – almost half of the spending is done by just 5% of patients – like our IV drug abuser and our asthma patient. The debate over end-of-life care for mortally ill patients is an important one, but it overlooks the cost of these younger patients, who are merely irresponsible. The former question rouses passions; the latter just feels kind of sad and intractable.

And it’s not as though we aren’t moving mountains to prevent readmissions.  Frequent readmissions carry huge financial penalties for a hospital, and so our hospital administrators are as frustrated by the problem of frequent fliers as doctors are.  So we have all sorts of initiatives to help these patients get back on track.  We gave the asthmatic lady bucketloads of free medications and meticulously demonstrated how to take them.  We carefully write up prescriptions for any conceivable medical equipment they need so that they won’t have to pay much out of pocket.  We staple printouts explaining the same concepts in simple language.  We even offer to send home care nurses around to reinforce the lesson at home in a few weeks.

And, well, all of these are good things to do, and I’m sure some patients on the margin benefit from all this.  But ultimately, it all still relies on our patients’ willingness to take their medication, and if they don’t want to, we can’t make them.  So we give them a bag of medications, declare them fit to make their own medical decisions, and wait expectantly for their next admission a few months from now.

 

Stanton, Mark W., and M. K. Rutherford. The high concentration of US health care expenditures. Washington, DC: Agency for Healthcare Research and Quality, 2006.

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