Our threshold to admit a patient into the hospital is high. They must be sick—really sick!—and therefore once they are admitted, worked-up and treated, their prognosis is inevitably better. Ultimately, that is the point of our health care system. Enter sick, leave healthy. A recent patient encounter made me question this basic premise.
Here was a 56-year-old white female with a past medical history of chronic obstructive pulmonary disease (COPD) presenting with increased shortness of breath, worsening cough and purulent sputum. It was a classic COPD exacerbation likely secondary to pneumonia. Unfortunately, the remainder of her story was far more complex. She was homeless; she split her time under a bridge and in a shelter if she got lucky. She had little to no access to medicine and had poor compliance with inhalers. She was certainly no candidate for oxygen therapy. She smoked one pack a day for 46 years and currently smokes one to two cigarettes daily. She came to the emergency department sick, wheezing and gasping for air.
It took this woman many decades of smoking, a few debilitating episodes of pneumonia during the winter, and a lifetime of poor living conditions to get to this point. Suddenly, the “enter sick, leave healthy” attitude is the “enter super sick, leave at least livable at best-case” scenario. Medically speaking, implementing the COPD exacerbation protocol was relatively straight-forward: oxygen, multiple nebulizers every couple of hours, intravenous antibiotics and steroids. As expected, she did improve to her baseline. Unfortunately, her baseline was still very poor and kept her at a constant risk for readmission for similar exacerbations. This was a situation where medical professionals would continuously put bandages on a situation that required something significantly more.
On that note, a question that repeatedly came up during this patient’s hospitalization was when to discharge her. Was it when she was at baseline, or once she could survive without oxygen? What about when she stopped coughing up that junk? Or what about when she stopped requiring rescue inhalers? Ultimately, she was discharged when she was able to maintain oxygen saturation while being on room air. Social work was critical in her long-term prognosis and follow-up, as well as reconnecting her with the local community hospital for frequent checkups and medication refills.
This particular experience was uncomfortable for me. Here was a very sick woman who came to me and whom I ultimately discharged as a very sick woman. Did I make any real progress, or just delay the inevitable? I certainly spent a lot of taxpayers’ money, utilized hospital personnel and arguably shunted valuable resources away from “enter sick, leave healthy” patients. What would you think?
Patients are the true storytellers. They come in with pathology, we interpret physiology and prescribe pharmacology, but their stories are what we remember. They shape our experiences and how we practice medicine.