March 03, 2008
The Uninsured Patient
Shiban Ganju
My pager beeped while I was standing in line in Starbucks. I checked the message – it was the telephone number of the ICU. I ordered my coffee and stepped aside to call. The nurse informed me, that I was asked to consult on a 33-year-old patient who had been admitted the night before. He had uncontrolled diabetes and had vomited blood.
What is the hemoglobin?
Thirteen.
Not bad. Is he on any anticoagulants?
No.
Any history of alcohol?
No.
Any aspirin or ibuprofen?
No.
I grabbed my grande and rushed to the hospital. In my mind, I rearranged my schedule for the day and decided to start with this patient in the ICU. I figured it will take me a few minutes, but I was not prepared for what I saw.
An oversize man lay sprawled on the bed from one side-rail to the other. He looked bigger than his stated weight of 367 Lbs. His gullet rattled behind the oxygen mask, as it croaked with each breath; beads of sweat glistened on his balding scalp; his huge flaccid limbs lay motionless. His pale face announced impending death. I glanced at the monitor: his heart galloped at 120 beats and his blood oxygen level touched a critically low number.
“Get me a blood gas and call respiratory.”
I sensed the danger. In a few minutes, the blood gas result showed that his oxygen level and pH (blood acid level) were incompatible with life. The respiratory team showed up and we inserted a tube into his trachea and connected him to a ventilator.
We injected sodium bicarbonate to neutralize excess acid in the blood and rushed in more intravenous fluids. The numbers on the monitor showed improvement. We sighed relief.
Now we had a small hiatus to recapitulate. JD was a truck driver on a long haul and had become nauseous and dizzy driving on the highway, six hundred miles away from his home. On seeing a hospital sign, he had got off the highway and staggered into the emergency room. JD’s life was succumbing to diabetic keto-acidosis, also called diabetic coma. An untreated bronchitis had progressed to pneumonia, which had triggered this disaster.
He was now temporarily stable for me to inspect his stomach for bleeding. I slipped a fiber-optic endoscope into his esophagus and advanced it into his stomach and duodenum. Flecks of blackish curdled blood covered the stomach lining. I searched every corner but could not find any fresh bleeding, which was good news, but it also made me uncomfortable because I did not know why he had bled. I had expected to see small ulcers, but he had none. I stopped the procedure and pulled out the ensdoscope.
I called the primary physician and updated her about JD and advised her to request pulmonary, endocrine and infectious disease specialists to see this patient. We needed more help.
Before leaving, I enquired if JD had is family around.
I walked up to the waiting room. Two ladies, with fear on their faces, approached me and introduced themselves as the mother and wife. I explained to them in simple language about his serious condition. This was the time to know his story.
How long did he have diabetes?
Two years.
What medicines was he on?
He was trying to control it by diet.
Is that what his family doctor had recommended?
No, he had prescribed some pills but he never followed up.
Why not?
He had no insurance - we have no insurance.
JD was a hard working honest man who was teetering at the edge of life because he could not afford health care insurance. About eighty percent of all uninsured people belong to such working families. Even middle class families find health insurance beyond their reach; about 40 percent of uninsured have a household income of $50,00 or more.
His employer had dropped health insurance because he could not afford exorbitant insurance premiums.
I looked at my watch: we had been there for two hours, which meant I would spend rest of the day trying to catch up. The accusative looks of the patients waiting in my office haunted me especially. I decided to go to my outpatient office first and postpone my hospital rounds for the evening and I would just apologize for being tardy.
Close to the end of my office hours, I received a call from JD’s nurse. JD had again vomited blood and he had produced no urine since the morning; his hemoglobin had dropped to 8 grams suggesting serious blood loss and his kidneys were failing. I asked the nurse to transfuse two units of blood, get a kidney specialist to see JD and get ready for a repeat endoscopy. I hurried my last patients out of the office and rushed back to the ICU.
I reinserted the endoscope into JD’s stomach. It looked completely different. Dark red blood had filled the stomach. Again, I searched for the bleeding spot and could not find it. In frustration, I decided to pull the endoscope out, when a slightly brighter shade of red caught my eye; the blood in the upper part of the stomach looked fresher than the rest of the stomach. This was my last chance. I pumped in more air to distend the stomach and we tilted JD to move the blood out of the upper stomach. And there it was: a miniscule of a nipple, one millimeter of a blood vessel squirting fresh blood with each heart beat. I had to stop the bleeder or JD would bleed to death.
Give me epinephrine.
I injected epinephrine into the bleeder. It still squirted.
Give me a clip.
I attempted to staple the bleeder with a metal clip but my clip missed the constantly moving target. Give me one more clip.
Second try failed.
Give me one more.
Bingo! I got it! The clip strangled the nipple in its jaws. The bleeding halted instantly.
I checked his chart; all the consultants had seen JD and initiated intensive management. I talked to the family again and finally went to complete my hospital rounds, about ten hours late. I would again be apologetic to the waiting patients.
If JD could have afforded it, he would have seen a primary care doctor and controlled his diabetes. If JD had cared, he would have not grown to a mammoth size; his callous eating behavior and the inefficient health system had landed him in this intensive expensive care, which could have been avoided by spending much less on prevention.
Between 2000 and 2005 the average annual increase in insurance premiums for small companies was 12 percent compared to 2.5 percent inflation rate. About 266,000 companies, mostly with less than 25 employees, cancelled their health insurance between 2000-2005. Even when employers offer insurance, high deductible and co-payments become prohibitive for some employees. The percentage of employed people with insurance has decreased from 70 percent in 1987to 59.5 percent in 2005.
JD and unfortunate people like him cost $100 billon annually to the health care system, out of which hospitals provide $34 billon worth in inpatient care for which they are not compensated. They shift the costs to paying patients to stay solvent.
Uninsured people spend about $ 26 billion out of pocket and rely on emergency departments. The uninsured have up to 50% more chance of being hospitalized and have higher chances of dying early. Experts have estimated that the number of excess deaths among uninsured between the ages of 25-64 is about 18,000 a year.
Unfortunately, the political debate in health care hovers around one question: how do we provide health insurance to all? This politically popular question misses the point. The correct question should be: how can we make health care affordable? Unless we ask the right question we will not get the right answer. As long as health care is expensive, health insurance will be unaffordable. Various studies tell us that 164,000 to 300,000 people loose employer paid health insurance if the premium increases just by 1%. The right reform will have to answer the question of cost or the reform is unlikely to succeed.
Spending more money is not the answer. Health care expenditure increased from $ 1.4 trillion in 2000 to $ 2.1 trillion dollars in 2007, yet in the same time about 8 million more people lost their health insurance. A universal health care coverage without cost control is unlikely to succeed. Recent failure to provide universal coverage in California proves this point. We are in a crisis, but we do not want to debate the costs because the answers will be unpopular.
Yet, amidst all its inefficiency the American health system does succeed. JD recovered almost completely in three weeks and went home - exhausted and a few pounds less. Studies have shown that among the industrialized nations, the US health care is the most expensive but also most likely to deliver the ‘right care’. The US health care triumphs, when it delivers.
Epilogue: About six months later I received a card from JD and his wife. The hand written cursive note in blue ink thanked me for my services. JD was unable to work for five months but had been rehired a month back. His wife had picked a second job in housekeeping in an office building. They had applied for Medicaid but the state had rejected the application; they were not poor enough.
Posted by Shiban Ganju at 04:00 AM | Permalink
Comments
This is not only the stark reality, but the reason why more and more physicians are abandoning medicine in the USA.
This a problem that neither Obama nor anyone else can fix.
The lobbies that pressure our venal congressmen and even presidents is too strong.
Just as an asides, Dr. Ganju: "nauseous" should have been "nauseated". I enter this comment in sympathy and respect to you, since English is my adopted tongue as well.
Posted by: Felix E. F. Larocca MD | Mar 3, 2008 11:05:12 AM
Felix,
Exactly right. There is no mystery here - greedy health care vested interests including the AMA, health insurance companies and pharmaceutical companies have bought politicians and corporate media to ensure that the 4 trillion dollar cash cow called the US health care system remains a for-profit system. Money truly is more important in this country than human life. It's disgusting.
Posted by: Jared | Mar 3, 2008 11:12:12 AM
Cogent, illuminating and beautifully done as always, Shiban. Many thanks for using this tragic story to place the focus on prevention -- which must include "caring" on the part of the patient -- and on cost containment. In another, more enlightened system, in almost any other Western democracy, your ER patient would neither have become so desperately ill nor had his life saved once he did. Whoever the next president is will have a hard time with all this; meanwhile -- here's a good look at what President Bush really meant when, months ago, he remarked, "There's always the Emergency Room."
Posted by: Elatia Harris | Mar 3, 2008 11:25:16 AM
Here are some thoughts. The average middle class taxpayer in good health does not trust insurance companies, does not trust the government to spend money wisely, and does not like the idea that those that don't contribute to the system are being cared for by those that do. I'm not defending these fears, just pointing them out
Posted by: eric | Mar 3, 2008 11:30:18 AM
Felix,
On the issue of usage that you raise, I am afraid that Merriam-Webster, at least, is on Shiban's side:
nauseous
1 : causing nausea or disgust : nauseating
2 : affected with nausea or disgust
— nau·seous·ly adverb
— nau·seous·ness noun
usage Those who insist that nauseous can properly be used only in sense 1 and that in sense 2 it is an error for nauseated are mistaken. Current evidence shows these facts: nauseous is most frequently used to mean physically affected with nausea, usually after a linking verb such as feel or become; figurative use is quite a bit less frequent. Use of nauseous in sense 1 is much more often figurative than literal, and this use appears to be losing ground to nauseating. Nauseated is used more widely than nauseous in sense 2. [Emphasis mine.]
P.S. While we are trying to get our English usage right, in your comment, it should be "The lobbies that pressure our venal congressmen and even presidents are too strong," and also it should be "Just as an aside" in your last sentence, and at least according to standard American writing, the period should be within the quotes surrounding the word "nauseated." But then, English is not my first language either. ;-)
Posted by: Abbas Raza | Mar 3, 2008 11:44:40 AM
Elatia,
While the article raised the issue of personal responsibily for one's health, its focus was on the lack of options available to the uninsured. The priority must be to insure all Americans.
Eric,
I have encountered the attitude you describe. A co-worker assured me that "Americans don't want to pay for other people's operations" Just remember, today you are in perfect health; tomorrow you may be that "other person" needing an expensive operation. A little empathy would go a long way.
Posted by: Jared | Mar 3, 2008 11:48:05 AM
Health care that new old argument that has been dogging the debates all year has become a topic of great concern in our household. We both have health care insurance and are fairly regular in our use of it for check ups and medical needs. But this year we have learned anew that old saw, the doctor is only human.
Around four months ago my wife, T, began feeling a consistent pain in her right side. Since it was also accompanied by an upset stomach and a soreness in her jaw, we felt that we needed to get it looked at immediately. So we went to the ER were she was admitted and had her blood tested and then was examined. The doctor prescribed a sleeping pill and a medication for calming her upset stomach. Two nights later, after a daytime visit to her personal physician, we found ourselves back at the ER. Another attack of pain so severe we knew she needed help. This time the ER doctor, after reviewing her CAT Scan, prescribed more stomach pain medicine and told her that she needed to see her personal doctor about it.
Her doctor, apparently after reviewing the information, referred her to a gastro-entrologist and away we went. Within a week, T, was in his surgery and being scoped, as they say, from top to bottom. The not so funny thing is that the scoping found no anomalies except for a long colon, a possible growth that turned out to be benign. Whew! we were relieved but then puzzled as T’s pain persisted and indeed the one in her jaw increased. So in the midst of worrying about why her side pain didn’t go away, her dentist diagnosed an infected wisdom tooth that needed to be removed. At this point, now some three months into it, T was only able to sleep via the sleeping pills.
Enter the Google Health Care plan. In February, I decided that it was time to research this problem myself. I know, what the hell had I been thinking? Trust the doctors? First, using a general search, I looked for info about her symptoms. Almost immediately, I was pointed to the gall bladder or liver as being the source of her side pain. The next step was a trip back to the doctor where I insisted on being in the room for the exam. T told me that this was the first time he had actually performed a physical examination of the area in pain. His immediate referral for an ultrasound exam was further confirmation that we were onto something. That exam revealed the presence of gall stones, sub-centimeter sized echo-densities. We then were referred by her doctor to a surgeon.
That’s when we discovered that her insurance, a PPO, wasn’t accepted by the surgeon. Meanwhile, I was back to the net and ordering a month’s supply of the GallCleanse formula. T continued to work and struggle with the pain, and use the sleeping pills. Last Monday, she started the cleanse. Tuesday afternoon she had a severe attack of abdomen pain, her face became flushed and we rushed her to the ER again. The pain subsided slightly during the five hours we waited for her to be examined but at the end of the exam we had another referral to see a surgeon. One who was on her insurance plan. Friday, we met with him and after a discussion that included his casual and dismissive look at the cleanse medicine, T decided to have the surgery that afternoon. I was convinced that the attack she had indicated that the cleanse had started immediately to work and that she had simply but painfully passed a stone. The surgeon’s assurance that dissolving the stones might lead to blockage convinced T to have the surgery.
We will never know if the cleanse would have continued to work as promised. She was in pain for four months. Her personal doctor had treated her as though she had an upset stomach. If we hadn’t gone to the Internet and Googled for our information, who knows, maybe his next guess would have been cancer, remove her stomach, ??? We do know this, without the use of the Google search we would have spent (the original colon scope, tests, and exams cost $4ooo above our insurance coverage) more time and probably money waiting for the doctor to actually figure it out.
Could this have been a case of an incompetent doctor, I don’t know? I subscribe to the theory that the doctor too often hears what he or she wants to hear and quite often turns out to be just a human who makes mistakes. I do know that in this day and age, if you don’t do your own research, you may be being fairly incompetent, too.
Posted by: rhbee | Mar 3, 2008 11:56:41 AM
Jared,
You misunderstand. What you can do -- with health education -- to manage your risk is a vitally important aspect of a more enlightened system than the one we have, a system that goes at cost containment from every angle. It's not the same as too few options for the uninsured, or meting out just desserts for poor self-care. Years ago, my doctor -- one I can no longer afford to see -- had a questionnaire for new patients -- family medical history and other routine questions. The final question was, Do you use seat-belts always, sometimes or never? Intrigued, I asked her about that... Just checking how badly you want to live, she answered.
Posted by: Elatia Harris | Mar 3, 2008 12:09:26 PM
Bravo! Nice post!!
It reminds me of the interesting 60 Minutes story last night.
Anyone catch that one?
(Minor quibble: The patient was in ICU in that state and the nurse hadn't had respiratory involved and a blood gas done already??)
Posted by: beajerry | Mar 3, 2008 12:12:45 PM
Elatia,
Good thing I never told my doctor about the hang gliding and mountain climbing!
Of course you are right. Preventative self-care is very important. I actually believe that the body can usually take care of itself giving a good diet, exercise and the avoidance of bad habits like smoking. If I get a cold, I rest in bed for 2 or 3 days without taking any medication. Why do people smoke and allow themselves to become obese? These are difficult social problems that must be addressed, not just here but in countries, like Canada, that have universal health care. But we should start with single payer universal health care since the US is one of the very few countries that still does not have it.
Posted by: Jared | Mar 3, 2008 12:20:53 PM
Of course containing health care costs is very important, and preventive measures are a very important part of that. But you can't prevent every malady, obviously, and people who work in the health care field need to earn a living like everyone else, so there is a theoretical floor to those costs, which might turn out to be higher than a lot of people would like to think it is, especially if everyone is to get a high level of care, which they should.
I suspect that the old AMA, back in the good old days, was right when it warned us of "socialized medicine." In the end, I think, we are just going to have to confront the whole question of why we can't have socialism in this country. Americans are so individualistic and selfish; we always have been. Eric and Jarad have put their fingers on the essence of the problem.
As has been frequently pointed out, we are perfectly happy to have socialistic highway systems, police and fire departments, armed forces, and garbage pickups, but medical care? Heaven forbid! The poor who can't afford good care should just die off; social Darwinism is just the thing for health care. And neither Democratic candidate has an adequate plank for this problem, so the petty little squabble between them about "mandates" is just a waste of time.
Posted by: JonJ | Mar 3, 2008 4:30:24 PM
"Jared," sorry.
Posted by: JonJ | Mar 3, 2008 4:33:39 PM
Beajerry,
Thanks. regarding you 'minor quibble': I have altered some events and their sequence to maintain patient confidentiality. I also had to make it readable for non-medicos, so I took some liberties.
My purpose was not to illustrate proper medical management of diabetes but to focus on the cost of health care, which no one can afford now. Health insurance for all without cost control will only increase profits for many. I hope I got that across in my story.
Shiban Ganju
Posted by: shiban agnju | Mar 3, 2008 7:11:24 PM
Abbas
Thank you for the useful comments!
And... hasta pronto...
Posted by: Felix E. F. Larocca MD | Mar 3, 2008 8:03:43 PM
I belong to and support a nice organization called Physicians for National Health Care. If anyone cares to check it out:
http://www.pnhp.org/
Posted by: Bryon | Mar 3, 2008 10:38:50 PM
A family friend of ours who is a physician in Florida, once told us that, where he to come accross a drunk lying unconscious in the street and treat him, he might well be sued for assault and for applying treatment without patient consent. Of course, were he NOT to treat the drunk, he could be sued for medical negligence. Thanks to the lawyers who rule the US and so many other countries, malpractice insurance rates for physicians are super high and the cost of health care is further inflated by the barrage of unnecessary tests that physicians routinely order so as to cover their asses against malpractice suits. This trend has also arrived in countries with national health services, like Britain Israel etc. Basically, you could reduce healthcare costs by accepting a slightly higher likelyhood of mistakes and lower levels of compensation.
However, you have to face the fact that health costs are always going to go up, if only because more and more people are surviving (at a high cost to the health services) health crises that just 30-40 years ago were nearly always fatal, like cancer and chronic heart disease, and live on to succomb to even more expensive conditions like old age. Of course, there are miracle health products like Soylent Green...
Posted by: aguy109 | Mar 4, 2008 3:09:02 AM
I sold my house to pay for medical bills from my experience with asthma. I am a working single mother and I have not been insured in 17 years. The new Asthma meds on the market are like a miracle, but, I can't afford them....I get samples from friends and friends of freinds and then ration them.
I was born and raised in this country. I have been working since age 16 and volunteering since 14.
Thank you for sharing JD's story from a doctors perspective.
Posted by: T | Mar 4, 2008 4:04:38 AM
Great piece. Thanks Shiban. The curious thing is that of all the physicians who read this blog constantly, very few commented. Are we too tired of these problems that are sort of like the backdrop of everything we physicians do to even throw in our two cents? Just as we all breathe the filthy air and drink the polluted water because it's the only air and water we have-health care providers are trapped. Do we leave the profession we are called to because it seems irretrievable, or do we continue to work within it and do whatever good we can?
The sad thing, speaking as a pediatrician, is that JD was not obese and diabetic because he didn't care enough or even solely because of the current flaws in the health care system. Let's not forget the financial pressures his family may have been under, thereby feeding him cheetos and tv dinners and letting him sit in front of the TV all day instead of buying the expensive tennis lessons and fresh fruits and vegetables. The whole cultural training he received is deeply flawed, and he passed it on to his offspring. It kind of makes one's head spin if you start to really consider all the demons modernity forces us to wrestle with. And yet, I'm off to my own set of afternoon rounds on patients with poorly controlled asthma because they can't afford the meds, abused babies of stressed out alcohol addicted parents, kids who lose part of their eye because they didn't have a doctor and waited to go the the ED till their infection was really too bad to look at anymore...because they don't have insurance or a car or clean socks, for that matter....
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