Why wasn't Arthur getting better?

October 21, 2005

The patient seemed blas? about his critical health problems. In truth, he was acting more out of shame than indifference.

When Arthur Clarke first presented in the ED, he was in heart failure. At only 58, this strapping former New York City police officer had an enlarged heart and severe left ventricular dysfunction. An echocardiogram showed a very low ejection fraction of 25 percent.

It turned out that Mr. Clarke (not his real name) was suffering from dilated cardiomyopathy. Whether this was an idiopathic condition or a consequence of his moderate alcohol consumption, I couldn't be sure. With good medical care he improved, shed a few pounds, and was soon ready to go home. Medications adjusted and dietary instructions given, he appeared on his way to recovery.

A few days later, he was back in the ED complaining of palpitations. This time we diagnosed ventricular tachycardia. He needed immediate defibrillation and was stabilized further in the CCU. Before he was discharged I prescribed amiodarone, the effective but costly antiarrhythmic drug, and asked if he could fill and refill the prescription as needed. "No problem, Doc, I'm on my wife's insurance plan, which covers drugs," he said. About weight reduction, he bragged, "I'm going to lose 30 pounds in three months. You just wait."

A few weeks later he was in the ED again, complaining of dizziness and chest discomfort. We treated him for recurrent ventricular tachycardia, and referred him to an electrophysiologist for an EP study and AICD.

Another two weeks went by, and I spoke with him in my office. "Do I have to take this ammodiarone or whatever you call it, now that I have this gadget?" he asked, pointing to the left side of his chest.

"Yes, you do," I replied. "Otherwise, your AICD will discharge frequently. You don't want that."

He was put on a maintenance dose of amiodarone. With AICD and amiodarone, he should be okay now, I thought. But I was wrong. Not long afterward there was that all too familiar call from the ED. "Your man is here with the same problem," the ED doctor informed me. "He's had a few more bouts of ventricular tachycardia, and the AICD discharged twice."

"That's strange," I said. "He was well controlled on his medications."

When I saw Arthur in the CCU he appeared shaken. "What happened, Arthur?" I asked. "I didn't expect to see you so soon."

"Oh, Doc, I'm scared. And I have a confession to make."

"What is it? Have you started drinking again?"

"Oh, no. I stopped the ammodiarone weeks ago. It's expensive, Doc."

"But you have insurance coverage for prescription drugs, right?"

"I did. But my wife doesn't work anymore, so we have no health insurance now," he admitted.

"Why didn't you tell me?"

"Frankly, I was embarrassed to admit that I didn't have enough money to buy medicine. Can you dig up some from the hospital pharmacy to help me get by?"

So that's what was going on here. Arthur was deeply concerned about his health, but he was too proud to ask for help in securing the life-saving medicine he needed. "Sorry, Arthur, we can't do that. But I can help you get Medicaid benefits."