“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.

Every morning the hospital, we have a big meeting with all of the residents, nurses, and attendings from the entire floor. The ostensible reason is to make sure that everyone was on the same page about which patients are ready to go home, and to make sure that all the boxes are appropriately checked before they do so.  In reality, I suspect that at least half of the reason is so that Dr. Khan, who runs the meeting, can review the troops, drill sergeant style. It’s a very formal, spit and polish affair, everyone decked out in white coats, standing around the largest nurse’s station, the only one large enough to accommodate the two dozen people who show up.

“All right, let’s get started. Room 401,” comes Dr. Khan’s crisp voice. One of the interns straightens up, takes half a step forward, and reports “This patient came in for a stroke workup, CT and MRI were negative.  We’re awaiting the results of the echo, and once we have that back as well as a PT evaluation, they shall be ready for discharge.”

“All right. Call the cath lab and make sure the patient’s on the schedule today.”

“Yessir.”

“PT, you’ll be able to see this patient today?”

The physical therapist, a grizzled veteran of the hospital, barely leans up from his paperwork and says that yeah, he’ll see the patient this afternoon. He, of course, is outside the medical chain of command and has nothing in particular to fear from Dr. Khan, and always seems quietly amused by these proceedings.

And on it goes to room 402. It someone else’s time to jerk to attention, and God help you if you miss your cue even by a couple of seconds. The whole thing takes about 45 minutes, and it’s just one of those things that you grin and bear as part of the job.

One day, we got a call from the ER that we were admitting a patient who was sent to the hospital from a nursing home for “altered mental status.” This is a pretty broad symptom that includes anything from a little forgetfulness to confusion to being in a coma. And usually, you need to take a very careful history and to identify exactly what has changed recently, and what might be causing it.  Ideally we’d also ask her family members, because they have the best sense of how the person’s thinking has changed over time

In this case, though, it wasn’t exactly a mystery. As soon as he walked into the room, she started shouting “Where’s the baby? WHERE’S THE BABY?” and wouldn’t calm down for another five minutes.

Well, we had our mystery, and we immediately started to do the medical workup for altered mental status, which is pretty extensive. A lot of things can cause this sort of presentation, anything from a stroke to an infection to a psychiatric disorder. (You’d be surprised how often elderly people develop new mental illnesses – it’s not just a young person’s disease.)

Ultimately, both the CT and the MRI were normal, which pretty well ruled out stroke. The blood cultures were negative for any infection, but we had been treating her with antibacterial and antiviral medication just in case. The hospital’s psychiatrist got wind of this case and paid her a visit one afternoon. I’m not sure what exactly they talked about, but he slunk out of the room less than five minutes later, gave a long, multisyllabic sigh, grabbed the chart and wrote “please rule out medical causes and re-consult psychiatry as needed.”  Translation: “your patient – your problem.”

While all of this was going on, she was sitting outside the room, accosting anyone who’d walked down the hall with more questions.  “Where are you going?  Come back here!  WHERE’S THE BABY?” Usually this was just an occasional annoyance, something you’d chuckle uncomfortably at and laugh off as you walk past. But the one time we couldn’t avoid it was during Dr. Khan’s rounds. Every morning we’d start filing into the hallway around the nurse’s station, right in front of her room, and you could see her eyes widen as the hallway outside her room filled with a sea of white coats. As the last stragglers filed in and the hallway fell to silence, Dr. Khan would clear his throat and start, “Okay, let’s get started. Room – ”

“WHERE’S THE BABY? WHERE’S THE BABY?”

Her self-control, never that great to begin with, would give way. A nurse would rush over to her chair and try to calm her down and after a minute or two she would be pacified enough for us to continue. And another minute or two later, when some poor intern’s in the middle of getting grilled, she’d burst out again.  “WHERE’S THE BABY?”

Dr. Khan gave us a look. It wasn’t an angry look, or even a frustrated one. It was an incredulous look – “wait, patients can actually do the sort of thing? On my rounds?” It was all we could do to keep from bursting out laughing.

Ideally, once we’d ruled out the most common culprits, we’d want to get a lumbar puncture – a spinal tap – to retrieve a sample of the fluid in her spine and brain to make sure there is no infection there. But she was incredibly anxious, and would start hollering and thrashing around as soon as you spoke to her, so sticking a needle in her back was not exactly going to be a simple operation.

First we chased down the neurologist, who routinely performs this procedure all throughout the hospital. With our best pretty-please-with-a-cherry-on-top voice, we gently suggested that at this point in the patient’s workup, might it be a reasonable time to consider getting a lumbar puncture in this patient? The neurologist adjusted her glasses, looked us up and down a couple times as though wondering if we were the ones presenting with altered mental status, and said “gentlemen, with the way she is thrashing around on the bed, I really don’t feel comfortable doing a procedure at this time.”

Next, we called interventional radiology, where they have special expertise in doing these minimally invasive procedures. But when we tracked him down and told him the story, he took a deep breath and said “look, we really don’t just want to be the LP guys for the whole hospital. Try anesthesia first, and if they can’t do it, then get back to me.”

By this point it was getting late in the afternoon and I was getting pretty desperate.  I wasn’t even sure if the anesthesiologist was still there in the hospital, and if we couldn’t get this LP, there was no way we’d ever be able to send this lady back. The nursing home representatives would come out, take one look at her, and say “Wait, so you’re telling me that you gentlemen with your fancy degrees and white coats that only can’t fix her, but didn’t even do a complete workup on her?” Then they have a stern word with Dr. Khan, and Dr. Khan would have a stern word for me, and I’d spend the rest of the year mopping the floors, which wouldn’t be so bad, really, if not for the fact that every time I walked by her room I’d trip over my own feet when she let loose with another “WHERE’S THE BABY?”

But no, fortune was with me, and after a few minutes of phone tag I managed to get ahold of the anesthesiologist and breathlessly explain our plight. I waited with bated breath, but after a few minutes all he said was “okay, bring her down.”

The art of getting a patient into an elevator when she’s thrashing in a wheelchair, hollering “WHERE’S THE BABY,” and occasionally grabbing at doorways and passersby, is not something they teach in medical school. It ultimately involves a great deal of reassuring, deflecting her grabs whenever possible, and even singing some soothing songs. By the time we got her down the hall and into the elevator I felt I’d both aged a decade and been forcibly inducted into the mysteries of fatherhood.

But we got her down there, and sure enough, the anesthesiologist was able to get the procedure done with minimal fuss. We sent the fluid down to the lab for analysis, and I headed home for some well-deserved rest.

The next day, before we could get any of the lab results back, we finally succeeded at another arm of the investigation: getting in contact with the patient’s daughter so we could let her know that her mom is in the hospital. I carefully explained her mother’s condition to her, and described all the medications that we started her on and all the tests that we’ve tried. I asked her if she had any questions.

“You’re doing all that for my mom?” she asked.

I smiled warmly.  In a time when patient’s families often expect us to work miracles, it felt really good to bask in the gratitude of a patient for whom we really had gone above and beyond.   “Yes, of course,” I said. “It is a bit of a challenge to take care of her, at least when she’s in the state, but all of us are really coming together to do everything we can to make sure she gets the best care. It’s really just part of the job, and she deserves nothing less.”

“But why all the tests?  She always acts like that.”

I suppressed the urge to swear.  So she didn’t have some incredibly mysterious infection. This was just normal dementia which she’s been having for years and years. Someone in the nursing home either didn’t get that message or decided to send her to the hospital anyway. All the work we did in the last week, and all that she had endured in the course of these tests, was chasing after a mirage.

I took several deep breaths. I thanked her for her time, promised to update her as things progressed, and told her to call us if she had any questions. Then I had a terse conversation with the nursing home manager. Later that afternoon, an ambulance arrived to take our patient back to the nursing home.

The only silver lining of this saga is that for the rest of the rotation, I could make my resident jump two feet in the air by creeping up behind him and shouting “WHERE’S THE BABY?”

I did not try this with Dr. Khan.