When the best discharge may not be enough

The author shares his regret over not following up with a patient from years ago.

It was 5 p.m. on a Friday in the Pacific Northwest; the day was almost over. In two hours I was going to sign out to the night hospitalist. Then the inevitable happened: my pager went off.

The ICU had a patient ready for transfer. The resident started the signout saying, “I'm sorry. I just came in. I don't know much about the patient, but seems like an easy case.” The morning team had written a transfer summary note, which the resident read to me.

Sudhakar Karlapudi MBBS Photo courtesy of Dr Karlapudi
Sudhakar Karlapudi, MBBS. Photo courtesy of Dr. Karlapudi.

A 44-year-old homeless man with congenital adrenal hyperplasia presented two days ago in profound shock following acute viral gastroenteritis. He had not taken his adrenal replacement hormones and had required inotropes initially. He was off all pressors for 12 hours and was nearly ready for discharge but required prescriptions for medications.

Over the past two years I had come to associate words like “easy” and “simple” with some kind of an internal warning.

I chose to visit the patient in the ICU. Mr. M was five feet tall, looked frail, and avoided eye contact. He had been found abandoned as a seven-day-old child and was subsequently diagnosed with congenital adrenal hyperplasia. Since then, he had been on adrenal replacement.

I asked him how he felt. “Weak and tired but better,” came the response from Mr. M, who still avoided eye contact while continuing to stare at his smartphone. It is unusual for me to meet a homeless man who was also the owner of a Samsung Galaxy 3. So I asked him about it. “I bought an unlocked phone. I didn't activate it, but I can use the Wi-Fi,” he said.

I asked him why he had stopped taking his medications. “I ran out of them. I had only four weeks' worth when I left.” He told me he could find odd jobs and buy the medications when discharged.

Something did not add up. Here was a man who had to do odd jobs to buy prescription medications but at some point was able to afford an unlocked smartphone. This was not going to be an “easy one.” Something deeper and bigger was troubling this man. I pointed to the foot of the bed and asked, “Can I sit down?” He nodded.

“You said you left?” I asked.

“Yes, I left San Antonio, Texas.”

“Where are you from?” I asked.

“San Antonio, Texas.”

“When did you move to Portland?”

“Six weeks ago,” came the reply.

“What made you come here?”

“I do not know,” he said.

I was quite perplexed by his response. I asked, “Seriously, you moved halfway across the country and you do not know?”

Mr. M looked worried and responded, “Yes, I don't know.”

Then the floodgates opened. Mr. M was a highly qualified welder by profession with an annual salary of $120K. His adopted family, including two sisters, and his family, including his son and wife, lived in Texas. For the past year he had been embroiled in a bitter divorce and had been very stressed. For reasons that he could not remember, he bought a bus ticket for Portland and left Texas without informing anyone.

A week ago, he found his family looking for him on Facebook and left them messages relaying his location in Portland. He also told me that eight to ten weeks ago he was hospitalized for ingesting an unknown substance and did not recollect why or what he had ingested. He showed me a picture of a boy about age eight on his phone and I could see tears in his eyes. He said that he loved his boy very much and, in his right state of mind, he would not do anything to harm himself.

Adrenal crisis was now problem number two. Something had made this man indulge in an act of self-harm. Something had made him move halfway across the country without informing his family. While he remembered specifics of the journey, he could not explain why he chose to make it. I knew that discharging this man with prescriptions or medications would not be adequate. I was determined to do more.

I called the inpatient psychiatric service, asking for help in better understanding this patient. Was this a fugue state or an acute stress reaction or something else? The psychiatry resident called back, expressing concern for dissociative fugue versus unclear stress response. My patient did not meet the criteria for an inpatient hold and was not an imminent risk to himself or others. They stressed the importance of close and continued outpatient follow-up to help with achieving a diagnosis in this patient.

I had to discharge Mr. M. To safely do so, I just had to arrange a reliable outpatient psychiatry follow-up visit halfway across the country.

I reached out to his sisters. His younger sister told me that Mr. M was deeply loved by his adopted family. She had seen their mother give him hydrocortisone shots when he caught a cold as a child. The family had cared for him when he was admitted multiple times in shock from trivial trauma. They had supported him emotionally and financially during his divorce. She also told me that a year ago he suddenly disappeared and left for New York for no clear reason. The family had pooled resources to bring him back. This time they just did not have the resources.

I could sense her concern and desperation on the phone. These were tough economic times for all. She asked if there was any way I could send him back. She said that she would pick him up and could arrange for him to see a psychiatrist, and set him up with a primary care clinician.

A hospitalist's closest ally in challenging situations like these is often the case manager. My case manager patiently listened to me and nodded in exasperation. I could sense that this was not the only challenging situation she had heard about today. “I will talk to him and page you,” she said.

An hour later, I received her page, “Have bus ticket for Texas tomorrow morning, sister will pick up at Greyhound station.” I few minutes later, another page, “Medications available from our pharmacy, need scripts.” My joy knew no bounds. I sent in the required scripts and called his sister to confirm. Mr. M left the next day in time to take the 5 a.m. Greyhound to Texas. I sincerely thanked the case manager for her help and initiative, without which I knew that I would not have safely discharged the patient.

Two days later, I called Mr. M's sister and reached her voicemail. I left a message that I was calling to check if Mr. M had reached home safely and I left a number to call me back. It has been six months since I made that call. I never heard back from Mr. M or his sister again.

Today, when I think of Mr. M, I can't help wondering if I did all that I could have. Maybe I should have looked for local psychiatrists and primary care physicians and set up appointments for him. Maybe I should have called again to check with his sister. Maybe I should have done something else to close the loop in this discharge transition.

There are so many complicated aspects to the discharges that happen on a daily basis. But I worry for Mr. M and hope he was able to find help. I hope he is not on a bus heading someplace else, not knowing why he left.