Recently, one of our frequent emergency department users, an older woman with alabaster skin who I had last seen sitting in her motorized scooter outside our hospital one crisp fall morning, died. For emergency physicians, our weekly and sometimes daily interactions with patients who seem to return time and time again to the department can cause us to forge a close relationship with them, an experience that we often do not have with the vast majority of people who cross our paths. 

Our relationship with frequent ED users can be complicated. Many of these interactions can feel like aggravations because of the subacute nature of their medical needs. But over time, if we allow ourselves to be open to it, we bond with such patients and they become like family. These individuals often come from lower socioeconomic backgrounds and have complicating problems such as substance abuse and mental health issues. All of this can make it more difficult for them to engage in meaningful, long-lasting relationships with primary care physicians. In reality, due to our 24-7 availability, we in the emergency department become their primary care doctors, struggling mightily to reconcile their medications, address acute problems, and link them to the right care. One of our roles then must be to work diligently to assure that frequent ED users can access appropriate community resources.

While we all hope that the COVID-19 pandemic comes to a conclusion in 2021, emergency physicians must assure that our family of frequent ED users has the resources to weather this continuing storm. The resources that better-connected patients, those without mental health and substance abuse issues, have available to them—portable oxygen, the ability to safely quarantine, and effective pharmaceutical countermeasures against the virus—need to be available to our frequent ED user family as well. 

As vaccinations become available to the public, we must be sure that those who are most vulnerable also receive protection. In our community in Texas, we have partnered with hotels to provide safe spaces for quarantine to prevent spread of COVID-19 in homeless shelters and group homes. Drugs shown effective in treating COVID-19, remdesivir and dexamethasone, are available to patients requiring hospital admission. However, providing portable oxygen to patients who lack financial means or who might not be able to reliably keep up with expensive durable medical goods but who otherwise would not need hospital-based services remains challenging and often requires an out-of-pocket payment of at least $120 per month for those without health insurance coverage. 

I had a vision of my recently passed patient—pleasant, smiling, and happy—and in this dream, I imagined her real family at her side, caring for her as our emergency department family had done countless times and as we will do for the next person who takes her place as one of our most frequent visitors. I worry, however, that the unique strain that COVID-19 imparts on frequent ED users could prove fatal if we are not tuned into the needs of the most vulnerable members of our communities.