A Boomerang Patient

It is not unusual to see a patient for a timely “Transition Of Care” visit after a hospital admission and within a minute of entering the exam room know with all the bones in your body that this person needs to go back into the hospital.

The funny thing is that when that happens, if the patient has Medicare, we may indirectly suffer financially from such “avoidable readmissions”. We belong to an ACO, an Accountable Care Organization, which is one of the recent schemes Medicare created to save money. The hospital most of our patients go to, Cityside, is not part of our ACO, but we are at financial risk while we have absolutely no control over the hospital’s charges or readmission rates.

I mean, what else could I have done with Allan Beck?

He had rolled his tractor and broken half a dozen ribs a little while ago. Commendably, he didn’t want to go to the emergency room for nothing, so he had called and argued with the triage nurse about coming here instead. She thought she had him convinced, but half an hour later he showed up at the check-in window.

“Triage to the front desk” was announced and Dr. Kim ended up seeing him briefly and ordering ambulance transport to Cityside.

When I walked into the exam room a week and a half later, the muscular could-have-been-a-movie-star farmer was so pale and frail looking that he seemed to blend in with the faintly blue wall paint.

As the story unfolded between his laconic answers to my questions and my speed reading of the hospital discharge papers, it became evident that the day before discharge, he had substantial atelectases and possibly an evolving infiltrate of his left lung, but that his collapsed lung remained expanded with his chest tube gone.

“Yeah, I’ve been coughing up yellow crud since my first day in the hospital”, he told me.

He had almost no breath sounds in his left lung, his white blood count was up and his reds were the same as when he was discharged, one third down from his baseline. His X-ray showed what I had heard, a massive consolidation of much of his left lung – a nasty pneumonia or even empyema, pure pus.

The ER doc sighed. “OK, send him up.”

The irony is that there is a new scoring system that’s supposed to predict a person’s risk of readmission. Allan’s score was low. Everybody loves to use mathematical models, but when it comes down to it, clinical judgment and anticipating “the worst” would have been more valuable in the very moment that his last hospital X-ray was done.

2 Responses to “A Boomerang Patient”

  1. 1 Elizabeth Davoren October 30, 2017 at 12:14 pm

    reminds me of story when tests are done but little of comprehension of the results when combined with physical exam.

  2. 2 Mary Symmes October 30, 2017 at 6:31 pm

    What? Why? How did such a thing happen? Such a dumb, dumb thing.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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