Who sent me Mrs. Mottira?

One year out of residency, I thought I knew it all. But there are some immutable medical laws that aren't taught. One is that the sickest patients must arrive at 4:00 p.m. or later.

Since my office hours are from 8:00 a.m. to 5:00 p.m., by 4:00 I have visions of home (warm dinner, family, and maybe a walk). But in keeping with the aforementioned medical law, an elderly patient, whom I'll call Mrs. Mottira, walked in one day at 4:35. My last scheduled appointment is at 4:15, but I allow a 15 minute grace period to allow for traffic and parking delays.

Huffing and panting behind her walker, Mrs. Mottira literally collapsed into the triage chair. Our nurses and medical assistant tag-teamed her in an attempt to speed the process. One strapped on an automated BP cuff, another stuck a thermometer in her ear, and a third rattled off a stream of questions. Her son, who was with her, provided the answers.

When I walked into the room, I found Mrs. Mottira slumped in a corner chair, while her son perched on the exam table. "Who's the patient?" I asked, to no one's amusement. Before I could go any further, her son bombarded me with questions. He probed for a final diagnosis-this despite the fact that the only information I had was her vital signs and a list of medications!

Five different doctors, 20 bottles of pills Taking Mrs. Mottira's history, I found out that she had seen at least five different doctors in the past year. Unfortunately, she could only recall the names of a few of them. She had brought more than 20 pill bottles with her, some of which dated back four years. She was 72 and did not have a primary care physician. She had seen many specialists, all of whom wrote prescriptions for different medications, but she had no one to help orchestrate her care and follow-up appointments.

She said that every time she was in the hospital-about five times a year-a new doctor was assigned to her. Someone had told her we were accepting new Medicare patients, so she called our office for an appointment to try to prevent yet another ED visit.

Her physical exam was no surprise. She had cyanotic changes evident at her nail beds. I listened to her lung fields and found a symphony of wheezing and rhonchi. I asked if she had any inhalers and she promptly answered, "No." She had no prescription drug coverage and couldn't afford her medications on her fixed income of $650 a month. I then asked if she had a nebulizer. She looked at me with a puzzled expression, "What's that?"

I yelled for oxygen and a nebulizer treatment and sent the medical assistant on a fact-finding mission with the local hospital's medical records department. It turned up the fact that Mrs. Mottira had a prior episode of hypoxemia and was supposed to be on home oxygen prescribed at her last hospital discharge. When I asked her about it, she said, "I use it sometimes, but I don't think I need it. I just need something to give me more energy."

It took me about five minutes to get her to understand that lack of oxygen worsens fatigue and that her body is starved for oxygen. Then she looked at me in amazement and said, "No one ever explained it to me before, so I thought if I could breathe, I didn't need it." It turned out that she also had nebulizer equipment at home but that she didn't use it because she didn't know how to. "Some guy just dropped it off," she said. All I could do was shake my head in disbelief at how the medical community had failed her.