We are going to discharge B.T. today.  Now that her potassium levels are back up to normal-enough, and her heart function is back to good-enough, we deem that it is time to free up the bed.  She keeps stalling when the social worker is asking her where she will go and how she will get there.  She reapplies her lip gloss without a mirror, trying to show some strength and propriety, but doesn’t realize that it is too thick and running down her lip. She would be embarrassed if she knew. When B.T. finally says that her daughter might be able to pick her up on the way home from work, and that they might be able to find a new motel to move into by the end of the day because they are currently “in-between,” we check the box for good-enough to discharge. We tell her it’s better for her not to stay in the hospital too long; even though she is grateful for a consistent and clean bed to sleep in, that’s not what we are here for.  The social worker hustles out as quickly as she shuffled in.

We tell her again to kick the methadone, the oxycodone, the alcohol, the tobacco use. We tell her that the methadone can exacerbate her genetic heart condition where her heart takes a little extra time to recharge than normal, and perhaps could cause her to have another event like the two days ago where she passed out in the E.D. and her heart first stopped, then after CPR, started beating in an uncontrolled and unsustainable rhythm.  We had to use the pads to shock her back. We tell her that the alcohol will make her stomach ulcer worse, which will make her vomiting worse, which will make her potassium worse.  We tell her like we tell everyone that smoking make everything worse.  We tell her we won’t give her any more Oxy or methadone, she jokes under her breath that she will just buy more.

We check our boxes so we meet our standards for due diligence for discharge.  We patch her up and pack her bags with prescriptions and admonitions.  We sign all the notes, write the discharge orders, and close the chart.

Ten years ago, B.T. lived a different life.  She had a steady job, a home, a husband, and four kids, and she was able to make ends meet.  She didn’t smoke, barely drank, and didn’t use much for pain.  About seven years ago she had gastric bypass surgery and lost half her weight; she has been very happy with this change except now she vomits after most meals. About six years ago, her anxiety flared and she started smoking for the first time in her life; for the past six years, she has smoked a pack a day even though it seems to be in the way of her having surgery for back pain. She says she was diagnosed with scoliosis at 13, requiring these massive amount of painkillers lately.   Somewhere in there her marriage fell apart.  About four years ago she and many of her friends and co-workers got laid off from their jobs.  About three years ago she lost the house that she and her children lived in. That’s when she really noticed that her back pain and OCD revved up.  She kept having to look for stronger pain meds and eventually got referred to a pain center where she received scripts for oxycodone. Then her mother offered her some methadone, which she used, causing her to fail a urine test and get kicked out of the pain clinic.  She found a methadone clinic to provide her with pain relief, but they reduced her dosage when they found her heart condition.  She describes with zeal her two favorite gas-station beverages, the Bud Lite Strawberrita and the 211 Pineapple drink, which surprisingly do not seem to bother the ulcer she has developed, despite several each day.  She was living with her mother until recently when her father had to have his second leg amputated due to uncontrolled diabetes; it was just too much in one house.  She moved out with most of her kids and 2 grandkids and has been bouncing between motels ever since.

We tell her that she is good enough to make another go of it.  We schedule an outpatient cardiology appointment.  We gloss over the host of psychological, social, and addiction issues as they are just beyond the scope of this cardiology unit.  We cannot fix the world; we can only patch up your body to “good enough for discharge.”  We are doctors, nurses, and the occasional social worker.  But we are not set up to provide long term emotional, psychological, financial, and social support.  We will not help her find housing or employment.  We will not drive her to rehab.  We will not pay for rehab either.  We tell her to stop the drugs, tobacco, alcohol, because they only make her sicker.  She just wants to stop hurting.

I wonder how long before we see her again.