I Needed You Guys

Pete presented to establish primary care the other day. This 50-year-old gentleman had been out of most of his previously prescribed medication (except for aspirin) for nearly a year, having lost work-related insurance coverage. His medical history included hypertension, alcoholic cirrhosis, and heart failure, with a systolic ejection fraction of 20%–25% two years before; he had been symptomatic with leg swelling and orthopnea for three months. We refilled and reviewed the indications for essential medicines—lisinopril, furosemide, spironolactone, and metoprolol; we set up relevant repeat testing and scheduled a near appointment for follow-up.

His echocardiogram now showed a left ventricular ejection fraction of 10%—a decrease from previous. This was communicated to him at follow-up, and he was referred to cardiology for additional surveillance. His blood pressure had risen to 180/108, so the doses of two of his four antihypertensives were doubled.

After it was noted that he missed appointments in internal medicine and cardiology, he was sought out and invited to reschedule, which he ultimately did. However, he became ill at work the day before he would have been seen, so much that he was sent home. Emergency medical services were called to the house soon after he got there because he developed limb weakness. He became unresponsive as he entered our emergency room and thus was intubated. His blood pressure was elevated and peaked at 296/163. Computed tomography of his brain showed a 10-cm hemorrhage in the right hemisphere, with mass effect and a 2-cm shift of the midline. He did not recover consciousness and was determined to be brain dead by neurosurgery and neurology. This sad news was conveyed to Pete's mother, brother, and aunt.

I got wind of his admission hours after brain death was confirmed. I felt pain for his relatives, whom I had never met; he came alone for his two outpatient visits. This scenario played out nine weeks after my first office visit with him. I wondered on the drive home: what if these relatives had been visible in his corner as he received and navigated medical care? Pete had struggled with risky alcohol use and perhaps this affected his propensity to access care. Should the people who love a patient be excluded from his health maintenance program in the name of the Health Information Portability and Accountability Act?

There was a season in my career when I did not realize the (therapeutic) value of the relatives or friends who were present in the room as I attended to patients. Now I thank those who attend and participate for being part of the team facilitating medical care. But there are many patients who show up without the support persons they need and possibly have access to. The concept of “Take a Loved One to the Doctor” ¹ needs to be broadened to “Keep a Loved One in Effective Medical Care,” with provisions for information sharing between providers and nonmedical/family team members. The Patient-Centered Medical Homes we are building to enhance primary care should increasingly see each patient as a valued member of his or her community of family and/or friends.

Goodbye, Pete. You died at a young age from a complication of an ambulatory care sensitive condition. Although I didn't get to memorize your face, I hope we can improve our practice space to prevent “Pete-flight” from recurring today.