Waiting for Discharge...

The following anecdote was written by Kelly Donovan, a third year medical student at Chicago College of Osteopathic Medicine

On a late afternoon in mid-July I was finishing up my first Sunday on call as a third year medical student. I glanced over the patient list for 4 East, the internal medicine floor I had been assigned to cover. Familiar with patients in their eighties and nineties, I was surprised to see a 22-year-old patient admitted with acute kidney injury.  

He was a nice-looking young man in good spirits. Spanish was his first language, but he could converse pleasantly in English, stating that he felt “good.” I palpated his abdomen and listened to his heart and lungs. He reminded me of my own 21-year-old brother, and I could easily imagine him throwing back some beers with friends or tossing around a football.  He worked for a roofing company and had been subject to the sweltering Chicago heat for the last six days. The emergency department had surmised that his acute kidney injury was caused by severe dehydration. My internal medicine residents agreed and we began loading him with fluids. This was day two of Garcia’s hospital stay.

On Monday morning, Garcia continued to deny any complaints. His blood pressure was  high at 150/80, despite treatment with medications. Creatinine, a marker of kidney function, continued to be abnormally elevated at 4.1. Ultrasound imaging showed evidence of a complex cystic mass in the kidney, along with areas indicative of chronic kidney disease. Multiple test results were pending to figure out the cause, including a comprehensive immunology panel. The nephrologists consulting on his case recommended a kidney biopsy, and a follow-up ultrasound and CT scan, finding Garcia’s previous imaging results inconclusive.

  

On hospital day four, Garcia’s blood pressure remained elevated with kidney function stable but poor. On day five, the nephrologists ordered vein mapping in case the need arose for hemodialysis. The team suspected chronic kidney disease secondary to nephrotic syndrome; a biopsy would confirm this diagnosis. Day six was a lot like day five, except someone checked the urine for protein. At 6.5 grams per 24 hours, Garcia had nephrotic range proteinuria. This is when I found out that Garcia was a self-pay patient and thus unable to afford a biopsy.

The case manager suggested we discharge home and recommend he follow up at the county hospital. Unfortunately, County doesn’t take transfers. So, Garcia would have to start at the beginning by seeing a primary care doctor during clinic, and be referred to a nephrologist on staff. While this would save Garcia significant money, the case manager worried about losing track of him. Despite his worrisome blood pressure and lab values, he felt great. Daily, he denied any complaints and smiled pleasantly throughout physical exams.

Days 7, 8 and 9 followed. Garcia’s blood pressure gradually normalized, but his kidney function remained very poor. The medicine we originally used to treat his proteinuria caused elevated potassium and uric acid, so we had to discontinue it. His hemoglobin dropped, either due to the kidney disease, or because we were loading him with IV fluids. It wasn't clear if our interventions were helping or hurting. So, we just watched him for three days while waiting for Nephro to sign off on the case so he could be discharged.

On day 10, Garcia’s bed was empty. The case manager shared that he had finally been discharged. The immunology workup still pending, they promised to alert him to the results when available. He was instructed to look into programs that would help pay the cost of dialysis.

During Garcia’s hospital stay, he received competent medical treatment. However, patient care was lacking. The failure of communication lead to an excessive hospital stay and thousands of dollars the patient clearly could not afford. There did not appear to be an open line of communication between the primary doctor, the nephrologists, the case manager and the patient’s family. By day three, the patient was stable. Why did he stay an additional six nights in a hospital bed he could not afford? There was no need to observe the patient while waiting for the immunology panel that typically takes 2-3 weeks to process. Did the physicians not know he was a self-pay patient? If aware, would it have changed their treatment plan? Perhaps the nephrologists wanted to “solve” this unusual case. Why did it take them so many days to sign off on the patient? And, given the language barrier, did Garcia’s family understand the suspected diagnosis and prognosis? With better communication, these obstacles to cost-awareness could have been avoided and improved Garcia’s outcome.