Sirens and Lights

The Emergency Department is almost inherently a loud place. Squeaking stretchers, the hum of doctors’ conversations, machines beeping notice of the moments of a patient’s life. Silence in the ED usually only means one thing: a particularly sad case or tragedy. I don’t think that the department is actually quieter, but it’s just that the air is heavier somehow and everything is just a little more still. The first time I really felt that was a few summers ago when I was working at the Children’s Hospital of Philadelphia the day that a little girl came in who died after her grandfather accidentally left her locked in his car all day in the summer heat. It was easily one of the saddest experiences I had in three summers in the ED there. Today, I think, has added itself to that unfortunate list. I don’t know why there were so many kids in the ED today..and why so many kids with such serious issues: a teenager with HIV that’s progressed to fullblown AIDS (she now has pneumonia, sarcomas, etc.), an adolescent with advanced leukemia, a kid with a tumor… and the one that caused that horrible stillness in the ED, a 3 year old who was crushed by a lorry (aka goods carrier) and whose parents (1) refused the blood donation to help their daughter for religious reasons; (2) and then discharged her to transfer her to the free government hospital because they couldn’t afford CMC’s services.

I think that in the past week and a half, I’ve seen more than I did in nine months at CHOP. Much of that stems from the economic level of the patients CMC sees, but moreso from the way that uninsured patients are handled in this hospital, as opposed to in the U.S. In the U.S., the ED is a place that some uninsured people tend to flock to because the ED technically cannot deny care, even if the patient cannot pay for it. Thus, EDs are often abused in the U.S., with patients coming in for even minor problems. This pretty strongly affects the type of patients we see. In India, because uninsured people are required to pay for all of their treatments out of pocket, people are often hesitant to come to the ER…and when they do, the cases are often really serious. They’ll travel long distances to come to CMC, widely (and deservedly, in my experience) regarded as one of the best hospitals in India, and certainly in South India. In India, government hospitals offer free services, but the quality is considered low as they are overcrowded. Thus, people often prefer to come to the private hospitals. Often, they can’t afford the treatments, but have heard that CMC will sometimes provide services at a reduced rate or for free thanks to the support of their generous donors…so they will show up hoping to be lucky enough to receive some aid. Of course, while CMC does assist its patients to an incredible extent, they can’t always help everyone as much as they need…but the greater problem is that people often come and try to get services for cheap or free, even if they can afford more. All of this combines to a lot of heart-breaking cases where patients need to leave because they can’t afford services…and a lot of tension between doctors and patients as they “bargain” for health care costs and services. It’s really the doctors trying to assess what the patient actually can afford and appropriately reducing the actual price to a reasonable amount for the patient…and then getting them to actually pay it, but it can seem rather heartless to the casual observer, who will see the doctor call out for a nurse to discharge a patient who is clearly in need of further care. The nurse will then wheel the patient out to Quiet Counsel, and sure enough, ten minutes later the family will have come up with the money to pay the fee determined by the doctors. In reality, it’s all part of how things work here….like anywhere, even trying to be generous can backfire. Seeing this is the only thing keeping me from pushing the contents of my bank account at the patients…because I know that it leads to patients coming to the hospital thinking they’ll be able to receive top-notch care at an affordable price, when in the end it just leads to them having to pay a little for what they accept and then having to be transferred to the government hospital (the transfer isn’t always the best thing for the patient). It’s really bizarre knowing that I could make such a huge difference with what amounts to a small sum of money in my terms, even if I don’t know enough yet to do anything with my knowledge….but that if I decide to “help,” the outcome might be worse.

Not to sound horribly naive, but why can’t things just be simpler? *sigh*

This entry was posted on Wednesday, November 12th, 2003 at 4:57 pm and is filed under Emergency Medicine. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.