March 03, 2008
The Uninsured Patient
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?
Not bad. Is he on any anticoagulants?
Any history of alcohol?
Any aspirin or ibuprofen?
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?
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.
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.
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