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Frequent Flyer: Our Year with a “High-Utilizer”

Before we met Mr. Z, we met his medical record. As part of Duke Med’s Hotspotting program, my partner and I were expecting a patient with a high rate of Emergency Department use… just not 7+ ED visits in the last 12 months.

That did little to stop our eyes from glazing over when we reached our patient’s “problem list”: HTN w/ reduced L ventricular function; L ventricular thrombus; hyperlipidemia; gout; chronic polyarthritis; mature cataract; and history of cocaine, marijuana, and alcohol abuse.

What scattered social history we could and did little to brighten the picture. Mr. Z was undergoing housing resettlement, his previous neighborhood having been where his own brother had been shot. When it came to his medical visits, Mr. Z regularly refused urine drug screens and had admitted to using cocaine. Heads swimming, we arranged our first home visit.

The wrought iron barring the heavily curtained window rang hollowly as we shook it. Apparently, this had worked for Mary Hansen, a registered nurse with Duke who had worked with Mr. Z before. We had spent at least half an hour hammering on Mr. Z’s door, half an hour wishing we weren’t soaking up the wet summer air. But it was our rst meeting. And we were going to get our patient’s attention, one way or another. The door screeched open.

Mr. Z sported a dark T-shirt and jeans. We were expecting a man of roughly middle age. His features told a different story. His arms were thin, scarred by recurrent gout attacks. His right eye was milky. We made our introductions in the halting, unrefined cadence of nervous first year med students. His speech, filtering through the few teeth he had left, was hardly any clearer.

We followed Mr. Z into his home, keeping pace with his shuffling limp. The entryway was dim, with little of the sweltering heat following us inside. Together, we whittled down an extensive medical history to the issue at the top of our patient’s list – his right eye cataract. We called in an appointment with the Duke Eye Center and chalked up our first meeting as a success.

Over the next few months, it became our afternoon ritual to check Epic for the week’s appointments and to schedule transportation covered by Medicaid. Clearing the requisite ophthalmology consultations, our patient had nally been cleared for an extracapsular cataract removal.

On the fateful day, the afternoon glare threatened to wash out our laptop screens. We pulled up Mr. Z’s scheduled operation on the EMR. But where we expected the usual byzantine surgical itinerary: “CANCELLED BEFORE INDUCTION.” Our patient had used cocaine in the days leading up to his operation.

We asked Mr. Z about cocaine during our next home visit. “I didn’t know that I couldn’t do that! [The nurse] started asking me questions before the surgery, and I didn’t want to die on the table!”

“What have you done before to avoid using cocaine?” we asked. It turned out Mr. Z liked taking walks to his cousin’s house nearby. That was on the few occasions his leg pain did not keep him shuttered indoors. Cocaine staved off boredom. Cocaine took his mind o the pain. And when no amount of cocaine or pain meds did the trick, Duke ED was always open.

The recommendations we had planned to share with Mr. Z gave way to a cat and mouse game, chasing after the elusive strategy our patient would be willing and able to follow.

“If the [football] game is on, I don’t know if I’ll be able to keep off [the cocaine].

Or, “How about starting the next Monday… no… Tuesday after?”

Our goals had shifted beneath our feet, complete abstinence turned into remaining clean in the two weeks before surgery.

While working with Mr. Z, we also became acquainted with “NO SHOW”, yet another dismal status waiting in the EMR. In our disappointment, it was easy to wonder aloud to one another, “How did he avoid his appointment this time?”

Of course, it was not so simple. Between us, Durham Transportation Services, Medicaid, Duke, and Mr. Z, five parties were involved in arranging one patient’s medical visits. We did a fine job blindsiding one another, from the last minute reschedules we missed, to cancellations Mr. Z had never gotten word of, to transportation that arrived at his doorstep for an appointment everyone else knew was not happening.

One thing was simple to understand. Mr. Z did not have the independence to schedule his own appointments. He had precious few phone minutes to spare for keeping abreast of his many visits, let alone any unpredictable changes. Without a clear line of sight to his appointment schedule, Mr. Z had little on which to structure a drug abstinence routine. His cocaine usage only exacerbated preexisting conditions like congestive heart failure. The result was a cruel synergy between Mr. Z’s comorbidities and socioeconomic challenges, warping even a simple, vision saving procedure into an untenable idea.

Mugginess has since descended from a pale sky, heralding summer, bringing us nearly full circle to when we first met our patient. Once more, Mr. Z is taking the many steps between initial consult and surgery. Yet somehow, our view is di erent. Through Mr. Z, we now know that the gleaming expanse of glass in which we learn medicine does not have an intervention for a lack of phone minutes, or a personalized drug for each patient with a history of substance abuse. Mr. Z has grown beyond a constellation of poorly managed symptoms on Epic, instead becoming the gentleman in a faded denim jacket who waved over two medical students in the hospital lobby, greeting them warmly with a “How are my kids doing?”

The difficulties that would color so much of our shared experience is streaked by per- sonal moments such as these. Likewise, the templated labels we can hastily ascribe to our “di cult case” do not stick so well once we have left clinic and tested the air of our patient’s neighborhood, or pulled our chairs across the linoleum of his darkened kitchen. Eyes open, we realize just how intimate our view of this one patient’s life was. We find our frustration tempered and our resolve intact.

“You guys planning on still working with Mr. Z?” asked one of our Hotspotting coordinators.

My partner and I shared a glance. I shrugged, “We want to see this one through.”

Sabran Masoud is a rising third year medical student who frequently gets lost and sometimes enjoys it.