to the teeth

ER Dilemma:

what would you recommend to this patient?

37yo woman comes to see you in your clinic with swelling on the right side of her face, around the lower jaw. worsening for a few days. fever, chills, painful to open jaw or chew food. you diagnose a parodititis and due to poverty circumstances you try an injectable 24 hour antibiotic, ceftriaxone, with the knowledge that if it worsens overnight she knows you are going to recommend an ER visit with hospitalization for a more powerful antibiotic that has to be given intravenously every 4 hours, Nafcillin.

it's now day two, 6pm and she hasn't shown up in your clinic yet. when contacted by phone she says she just got off work and is feeling worse.

do you send her to the local public hospital? after calling there you find out they have no beds available and a long waiting list of people in the ER. if seen in the ER it will be a long long wait and they may or may not make a good decision about her care given the extenuating circumstances of how busy they are. she will likely qualify for at least 40% off her bill when it's all done.

do you send her to the non-profit "religious" hospital? the charges are much higher but she might be able to beg for a discount after care is done. i've had a handful of patients walk out of big surgeries or ER visits and have ZERO debt.

do you send her to the for-profit hospital? not a chance.

herein lies the rub for poor people considering ER care. it's a total gamble. public hospital with long wait, poor care, big bill or non-profit hospital with better basic respect, shorter wait in ER and a small chance for ZERO bill or a REALLY BIG BILL.

toss the dice... welcome to healthcare in the most powerful country in the world.

andru

Comments:

herein lies the rub for poor people considering ER care. it's a total gamble. public hospital with long wait, poor care, big bill or non-profit hospital with better basic respect, shorter wait in ER and a small chance for ZERO bill or a REALLY BIG BILL.

I'm not surprised about the differences in the bills, but I'm a little more skeptical about the differences in respect. In my very limited experience, the respect accorded a patient isn't as much a function of the type of hospital as of that individual patient's socioeconomic class. So, sadly, a lower class patient will get less respect at every kind of hospital.

But I'll defer to your greater experience. Either way, it's sad.

Carey

# posted by Anonymous : 1/25/2006 6:48 PM

i agree with your impression as a rule of thumb and add in Race and sexual orientation/gender. but when you get down to the nitty gritty in my local scene, there is a clear and overridding negative emphasis at the public hospital ER, regardless of your various identities.

here's one example from friends of mine. hispanic family, upper middle class, they were out for a family picnic, the father had 2 beers. not an uncommon thing in the united states. he cut himself and needed stitches. showed up to the public hospital ER and was treated like he was an alcoholic with all kinds of rude comments made to his face. i heard the story the next day from an outraged wife who is an employee of the university system.

that's the tip of the iceberg.

the pressures that create this environment are similar to Stanley Milgram's Obedience Experiments (check this out if you haven't already). none of the employees are evil or any worse than anyone else, including me. i got to be a real jerk towards the end of every ER shift I did as a resident. the context factors are stronger than the personal factors and noone is taking responsibility to improve the "system."

andru

# posted by andru : 1/27/2006 8:01 AM

this is a great blog and helps explain why we desperately need obama's health care reform including the public option.

# posted by tom from illinois : 9/02/2009 1:16 PM

Comments:

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