This story begins with a gentleman in his 50’s who had a condition recently recognized as the “dysmetabolic syndrome”.  The word syndrome describes a grouping of characteristics that all seem to represent the same disease process.  The prefix “dys” means disordered and the word “metabolic” has to do with the body’s chemistry.  Patients with the dysmetabolic syndrome tend to be diabetic, overweight, hypertensive, sometimes with gout, and with an inordinately high incidence of vascular disease such as heart attacks or strokes.  The gentleman in this story had all of the above except for diabetes.  Most importantly, he had a condition called gout in which the person makes too much of a chemical called uric acid which can cause kidney stones.

     This gentleman had developed chest pain and was subsequently diagnosed with having blocks in the coronary arteries that required bypass surgery.  He didn’t like medicines.  He didn’t know about the dysmetabolic syndrome that he had and he sure didn’t want to have coronary artery problems.  He was one of those individuals who felt that it was not natural to take medicines and felt that he just didn’t need them.

     When he developed chest pains, he visited with his primary care provider who referred him on to a specialty hospital where his bypass surgery could be done.  When it was done, the patient felt that he was cured and he didn’t need any more attention.  He knew that he sure didn’t need any more medicines.  When he left the hospital, he was told to take an aspirin per day to protect his coronary arteries but the cardiologist who cared for him felt that it was the home doctor’s job to take care of his gout so they didn’t say anything about it.  He came home without his gout medicine.

     Over the next six months, he made many uric acid stones and blocked off one kidney completely.  A catastrophe was now upon him and he lost the left kidney completely.  Sticking to his mentality that he didn’t need any medicine now that his kidney stones were removed, he again left the hospital with only an aspirin a day and several months later, he blocked off the right kidney.  Through a heroic effort by an urologist at the University of Minnesota, the right kidney was saved although in a damaged state.  Several years later, his right kidney also failed completely and he wound up needing an artificial kidney to sustain his life.

     This story illustrates the dangers that accompany leaving a hospital after treatment is done.  An article this week in the Annals of Internal Medicine followed a large number of patients that had left the medicine service of a metropolitan hospital.  Their purpose was to determine what happened to those patients in the course of the next month.  It was seen that 20% of them had a complication.  While some of the complications were unavoidable, it was felt that most could have been avoided by following several relatively simple rules.

     Rule # 1.  Review all of the medications when a person leaves the hospital.  One of the most common mistakes made was a deletion of a medication that the person took prior to coming into the hospital but not continued while they were there.  Blood pressure pills, diabetic pills, gout pills, cholesterol pills, etc. are often stopped when a person is acutely ill in the hospital.  It must be remembered that those conditions don’t just go away and need continued attention after the person leaves the hospital.  The medications that the person was taking before they came in the hospital need to be reviewed carefully to determine if they are still necessary and administered at the proper dose.  A written list of the person’s medications when they leave the hospital should be provided.

     Rule # 2.  Check back with your primary healthcare provider soon after the hospital stay.  If things are going to go wrong, they most commonly occur in the first week to two weeks after the hospital stay.  Being sure that the disease process treated in the hospital is adequately covered without recurrence and without medical complications is best done early.  Follow up of medication schedule and any side effects that may be occurring can be done at this visit.

     Rule # 3.  Be sure there is adequate support for the person wherever they go after leaving the hospital.  Hospital stays are rarely pleasurable.  Many people regard hospital stays with ominous gloom and doom.  All they can think of is that they have to get out of this hospital. “Please find me any port in this storm”.  Many times, the person goes home with inadequate support.  The result is often poor nutrition, inadequate hygiene, and inability to follow a medical regimen.  The person is often in a weakened condition and falls are much more common with potential for broken hips with resultant permanent infirmity.  Discharge planning and provision of adequate care after the hospital stay is critically important.

     Rule # 4.  The patient needs adequate instruction and education regarding future expectations.  Time needs to be taken to clearly explain what the patient can expect in the next several days and the next several weeks before returning to their primary care provider.  They need to know who to call if problems arise.  Sometimes patients are confused and unable to understand or follow instructions.  In that case, family support or home health care individuals need to be instructed regarding the patient’s care.  Home Health Care is available in some areas and is covered by Medicare under certain circumstances.

     Rule # 5.  “Too many cooks make a bad stew.”  Many times a person will go to a specialty hospital or specialist physician who only deals with one aspect of the patient’s care.  The primary care provider needs to be kept in the loop to orchestrate and coordinate medications and care plans.  Where two and three and four healthcare providers get involved in patient’s care and none of them know what the others are doing, problems are a promise.  There needs to be one primary healthcare provider, one captain for the ship, and one cook for the stew.  That healthcare provider needs to be aware of the patient’s needs and input from other healthcare providers.

     The story that started this column illustrates the disasters that can happen when the above rules are not followed.  The patient did not follow Rule # 1, and had a list of medications that he was on before he came to the hospital.  The cardiologist caring for him felt the patient only needed the aspirin to take care of  the heart problem so that is the only one the prescribed when he left the hospital.  His gout medicine was never re-prescribed.   The second rule broken involved is not returning to see his primary care physician until he had developed left flank pain secondary to the many uric acid stones six months after his heart surgery.  Had he returned within the first several weeks, the mistake of stopping his gout medication could have been rectified preventing the catastrophe that followed.   He broke Rule # 4 with the help of the heart doctors who cared for him.  They indicated that he should check back with them in six weeks and then he should get into a cardiac rehab program.  He didn’t know what a cardiac rehab program was or where to find it and felt that he didn’t need any help anyway so that never happened.

     Lastly, he broke the rule of having a primary healthcare provider.  When his backache occurred from the gouty kidney stones, he went to the chiropractor to treat his backache but never told the chiropractor anything about his heart problem or the fact that he had gout.  When the chiropractor checked his blood pressure and found it to be inordinately high, the patient finally returned to his primary care provider but too late to avoid the problems mentioned above.  In sum, leaving the hospital is a dangerous time.  The above rules can help avoid problems that often occur at this time of transition.  The healthcare providers at your local clinics need to be included in the care team, especially when patients are returning from distant hospitals where specialty care was provided.