1.

An Extended Stay
Ross Hilliard, MD, IHI Open School Northeast Regional Chapter Leader

Mr. Stanley Londborg is a 64-year-old man with a long-standing history of a seizure disorder. He
also has hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD).
He is no stranger to the hospital because of his health issues. At home, he takes a number of
medications, including three for his COPD and three — levetiracetam, lamotrigine, and valproate
sodium — to help control his seizures. Mr. Londborg came to the emergency department (ED) last
week because he was wheezing and having trouble breathing. The physician in the ED conducted
a physical examination that yielded signs of an acute worsening of his COPD, which is known as
COPD exacerbation. (In many cases, COPD exacerbation is the result of a relatively mild
respiratory tract infection, but could be due to something more serious, such as pneumonia.)

The physician in the ED ordered a chest x-ray, which did not show any signs of pneumonia. He
admitted Mr. Londborg to the hospital for treatment of acute COPD exacerbation, resulting from
a relatively mild respiratory tract infection. Before leaving the ED, Mr. Londborg also underwent
routine blood work, which showed an elevation in his creatinine, a sign that his kidneys were being
forced to work harder due to his infection. On the medical floor, the care team treated Mr.
Londborg with oral steroids and inhaled bronchodilators (standard medical therapy for his
condition), which resulted in a gradual improvement in his respiratory symptoms. Nurses also gave
him IV fluids for the issue with his kidneys, which slowly resolved. Mr. Londborg was steadily
improving, so it seemed this visit to the hospital would be one of his shorter ones.

But on his third morning in the hospital, Mr. Londborg complained to the intern (a first-year
resident) on the care team about acute pain in his left leg. This symptom, potentially indicating
deep venous thrombosis (a blood clot in his leg commonly known as DVT), prompted the team to
order an ultrasound of Mr. Londborg’s lower extremities. (A primary concern with DVT is that
blood clots in the legs may dislodge and travel to the lungs, causing a pulmonary embolism, which
could be deadly.) The resident on the care team (who oversees the intern) then checked Mr.
Londborg’s medication orders and was surprised to see that the admitting doctor had not ordered
prophylaxis for DVT (i.e., blood thinners, such as heparin or enoxaparin). The resident was
surprised because patients admitted to the hospital typically receive this treatment to prevent blood
clots from forming while they lie in their hospital beds. Further, nothing about Mr. Londborg’s
medical record suggested he shouldn’t have received this treatment as an important precautionary
measure.

The ultrasound, unfortunately, confirmed the presence of a blood clot in Mr. Londborg’s left calf.
Due to his impaired kidney function, treatment for the blood clot required him to remain in the
hospital on IV medication. Mr. Londborg’s stay was going to be longer than expected.
At 10 PM on his eighth day in the hospital, a member of the environmental services (also known
as housekeeping) staff found Mr. Londborg on the floor of his room. She immediately alerted the
nurses on the ward. The nurses noted seizure activity and called the overnight medical team to Mr.
Londborg’s bedside. The team responded quickly and gave him intravenous medication that
stopped his seizure. Because no one witnessed his fall and seizure, Mr. Londborg underwent an
emergent CT scan of his head to check for any sign of bleeding. After his mental status improved
(it is common for patients to be confused for a time after a seizure), he complained of pain in his
left shoulder and elbow, but x-rays of these joints showed no evidence of a traumatic fracture from
his fall. After ensuring that Mr. Londborg was stable, the overnight care team reviewed the chart
and the medication history to try to determine the cause of Mr. Londborg’s sudden seizure. They
found that one of his seizure medications, levetiracetam, had not been given earlier in the day when
it should have been.

There was a notation in the medication administration record from the daytime nurse indicating
that the ordered dose was not available in the automatic medication dispensing system on the floor
earlier in the day. Further discussions the following day with the daily care team of doctors and
nurses revealed that the nurses didn’t notify the physicians or the pharmacy that the essential
medication was not administered. The medication system didn’t include an automatic alert, either.
Fortunately, the overnight physicians restarted Mr. Londborg on his medication, and he suffered
no apparent permanent harm. Mr. Londborg was discharged after 10 days in the hospital. Most
hospitalizations for COPD are far shorter. In fact, many last only a couple days.
2. A Downward Spiral: A Case Study in Homelessness
National Health Care for the Homeless Council

Case: Married with two young children, John and his wife rented a two-bedroom apartment in a
safe neighborhood with good schools. John liked his job as a delivery driver for a large food service
distributor, where he had worked for more than four years. His goal was to become a supervisor
in the next year. John’s wife was a stay-at-home mom.

John had always been healthy. Although he had health insurance through his job, he rarely needed
to use it. He smoked half a pack of cigarettes each day and drank socially a couple times a month.

One afternoon, John’s company notified him that it was laying him off along with more than a
hundred other employees. Though he was devastated about losing his job, John was grateful that
he and his wife had some savings that they could use for rent and other bills, in addition to the
unemployment checks he would receive for a few months.

John searched aggressively for jobs in the newspaper and online, but nothing worked out. He began
to have feelings of anger and worry that led to panic. His self-esteem fell, and he became depressed.
When John’s wife was hired to work part-time at the grocery store, the couple felt better about
finances. But demoralized by the loss of his job, John started to drink more often.

Two beers a night steadily increased to a six-pack. John and his wife started to argue more often.
Then, about six months after losing his job, John stopped receiving unemployment checks. That
week, he went on a drinking binge that ended in an argument with his wife. In the heat of the fight,
he shoved her. The next day, John’s wife took the children and moved in with her parents. No
longer able to pay the rent, John was evicted from the apartment.

John tried to reconcile with his wife, but she said she’d had enough. Over the next few
months, John “couch surfed” with various family members and friends. At one point, he developed
a cold, and when it worsened over a few weeks, he sought care at the emergency department.
Hospital staff told him that he would be billed because he didn’t have insurance. John agreed, and
a doctor diagnosed him with a sinus infection and prescribed antibiotics. With no money to spare,
John could not get the prescription filled.
John continued to live with family and friends, but his heavy drinking and anger only got worse,
and his hosts always asked him to leave. He went from place to place. Finally, when John ran out
of people to call, he found himself without a place to stay for the night and started sleeping at the
park.

One night when John was drunk, he fell and got a cut on his shin. The injury became red and filled
with pus. John was embarrassed about his poor hygiene and didn’t want a health care provider to
see him. But when he developed a fever and pain, he decided to walk to the nearest emergency
department. He saw a provider who diagnosed him with cellulitis, a common but potentially
serious bacterial skin infection, and gave him a copy of the patient instructions that read “discharge
to home” and a prescription for antibiotics. John could not afford the entire prescription when he
went to pick up the antibiotics, but he was able to purchase half the tablets.

Winter arrived, and it was too cold for John to sleep outside, so he began staying at a shelter run
by the church. Each morning, he had to leave the shelter by 6 AM. He walked the streets all day
and panhandled for money to buy alcohol.

One evening, some teenage boys jumped John in park, stealing his backpack and kicking him
repeatedly. An onlooker called 911, and John was taken to the emergency department. Later that
evening, the hospital discharged John. He returned many times to the emergency department for
his health care, seeking treatment for frequent colds, skin infections, and injuries. Providers never
screen him for homelessness and always discharge him back to “home.”

One day at the park, an outreach team from the local Health Care for the Homeless (HCH), one of
about 250 such non-profit organizations in the United States, approached John. The team,
including a doctor, nurse, and case worker, introduced themselves and asked John, “Are you OK?”
John didn’t engage. They offered him a sandwich and a warm blanket. John took the food without
making eye contact. The team visited John for the next several days. John started making eye
contact and telling the team about his shortness of breath and the cut on his arm. The team began
seeing John frequently, and he began to trust them.

A couple weeks later, John agreed to go the HCH clinic. It was the first time in years that John
went to a health clinic. Upon his arrival, the staff at the clinic registered him and signed him up
for health insurance through Medicaid and food benefits. John felt comfortable in clinic, and he
saw some of the people who also stayed at the shelter and spent their days in the park. They were
happy to see him and told John about how the clinic staff care and would be able to help.

John began going to the HCH clinic on a regular basis. He saw a primary care provider, Maggie,
a nurse practitioner. In John’s words, she treated him like a real person. In addition to primary
care, the clinic offered behavioral health services. Both scheduled appointments and walk-in care
was available. John connected with a therapist and began working on his depression and substance
abuse.

A year later, John’s health has improved. He rarely needs to go to the emergency room. He is sober
and working with a case manager on finding housing.

3. Dealing with Burnout

Kate Ellis, M.D., Family Physician, Charles River Medical Associates; Morana Lasic, M.D.,
Clinical Instructor in Anesthesia, Harvard Medical School and Brigham and Women’s Hospital

Ana is a second-year resident in a demanding internal medicine residency program. She is

generally regarded as one of the most talented residents and has just been elected to the chief
resident position for the next year. For several months, however, she has been feeling a significant
amount of burnout. Ana’s mood has become low, her energy level has dropped and she is having
difficulty getting out of bed in the morning. She is in the middle of a very demanding ICU
(Intensive Care Unit) rotation, during which she is on call every third night, so at first she thinks
that it might just be sleep deprivation causing the problem. But she continues to feel increasingly
unwell both physically and emotionally.

To make matters worse, Ana’s mother was recently diagnosed with breast cancer. Her mother
lives over a thousand miles away, and it’s impossible to visit her, since Ana only has one day per
week off from work. Her mother reassures her, saying, “Don’t worry about me – keep working.”
Nevertheless, Ana can’t stop thinking about her mother and is having a hard time focusing on
medicine. She has to force herself to complete tasks and she stops doing the extra reading on
medical cases that she usually enjoys. She is feeling overwhelmed and increasingly hopeless about
life and, in spite of her many past successes, she is starting to regard herself as a complete failure.

Ana also feels that she is not able to care for her patients as well as she used to in previous
rotations. The other day when a patient was admitted with recurrent fainting episodes, she took a
brief history from the patient and did not do a thorough job asking about family history, missing
the fact that both the patient and other family members had histories of blood clots. As a result,
she did not think to work the patient up for a pulmonary embolus (blood clots to the lungs) even
though he had had some shortness of breath on admission, which is a common presenting symptom
of this dangerous condition. If a colleague had not thought about this possibility and suggested the
requisite testing, the patient’s life might have been in danger. Ana feels that she did not spend
enough time talking to the patient; she also feels that if she were doing her usual amount of reading
of the medical literature, she would have been better prepared.

Ana is worried because she was briefly diagnosed with clinical depression as a teenager, and her
symptoms are beginning to resemble what she felt back then. She knows, however, that she cannot
drop out of rotation; there is no one who can take her place in her ICU, and her not being there
would force the other residents to be on call every other night, giving them an intolerable work
load. Even if it were possible to find a substitute for the rotation, she does not have any vacation
time left and she can’t progress to the third year if she takes off any more time.

Ana is afraid to tell anyone how she feels because she knows that people in the program will start
to regard her as a “weak” resident if she complains. Besides, all the other residents are working
just as hard and don’t seem to be having any problem. She will not even discuss the situation with
her family at home because she does not want to disappoint them. She is feeling completely
trapped and wonders why she went into the medical field in the first place; she would do anything
at this point to escape it.