Link: http://www.usatoday.com/news/health/2009-09-07-emergency-room-healthcare_N.htm
USA Today, 9/8/09
Dr. Robert O’Connor had taken charge of the emergency room only minutes earlier when the cellphone in his pocket rang: The Western Albemarle Rescue Squad was on its way with a 14-month-old girl who had suffered a possible seizure.
Ten minutes later, Tyler McNeely climbed out of the ambulance, her face frantic and her pale, subdued baby in her arms. Shana Crabtree, a third-year resident in green scrubs, waited for them at the University of Virginia Medical Center. EMT Andrew Todhunter delivered a staccato summary of Clara’s vital signs.
“She was shaking and then she went all limp and then her eyes rolled up the back of her head,” Tyler McNeely, 37, said in a rush of words as an ID bracelet was clamped onto Clara’s wrist, her temperature taken, her responsiveness assessed. This is where we head when a baby is in distress, when chest pains may signal a heart attack, when a person with asthma can’t stop wheezing, when there’s nowhere else to go for help. Four in 10 Americans have visited an emergency room in the past year, a USA TODAY/Gallup Poll finds, either bringing someone else or seeking treatment themselves for problems life-threatening and routine. “(In) this whole health care debate, the ER is kind of like the canary in the mine shaft,” says David Burt, a cardiologist who specializes in emergency care at UVA.
The key elements of today’s debate on health care converge in the ER, from the cutting-edge quality of the U.S. system to the millions of uninsured people who show up for care. The debate reaches a critical moment this week, as Congress returns to Washington to take up proposals to revamp the system. President Obama will address a joint session of Congress on Wednesday to press for action.
To explore the issue, USA TODAY chronicled 24 hours in the emergency room at the UVA Medical Center, a teaching hospital and trauma center that serves patients across a swath of central Virginia. From dawn Monday to dawn Tuesday, Aug. 24-25, reporters talked with patients and their families, doctors and nurses, helicopter pilots and ER housekeepers about their experiences with health care and their views on changing the system.
Their experiences and observations underscore why changing the health care system has proved so hard for presidents and policymakers: the complexity of the system, the pressure from chronic diseases, the shortfall in preventive care, the high costs, the competing demands — and the life-or-death stakes.
Everyone agrees they want to preserve the quality and technological advances of American medicine. A 35-year-old man who arrived in the ER suffering a heart attack was taken within six minutes to the cardiac catheterization lab upstairs to have an artery opened and stent inserted — his life saved and the damage to his heart minimized. Beyond that, though, the consensus frays. Those with no or limited insurance want to see coverage expanded, while many of those with good coverage worry that changes will cost them more and disrupt a system they think works pretty well. Doctors, nurses and patients describe problems involving the power of insurance companies, the impact of lawsuits, the difficulty of getting a doctor’s appointment or specialist’s consultation, the rising and sometimes catastrophic costs.
Few of those interviewed have a clear idea of what’s included in proposals being considered by Congress, however, and almost no one expresses optimism that the debate is going to fix things.
“I’m glad the Obama administration has made this a topic of dinner conversations in everybody’s household,” says Allison Craytor, 34, who brought daughter Maggie, 3, to the ER. A gash on Maggie’s cheek — she fell while chasing 5-year-old brother Luke — needs two stitches. But it’s “not necessarily like we have an answer,” the stay-at-home mother adds, and she and her husband don’t always see eye to eye on what should be done.
As for Clara McNeely, the baby who arrived first thing in the morning by ambulance, her mood improved and color brightened within a few minutes. She looks around the pediatric emergency room, gnaws at the plastic ID bracelet on her wrist and wails when the exams continue. She reaches out to her father — “Baby!” she demands — when he arrives with her 5-year-old sister and 3-year-old brother. It would be nearly six hours before Clara is discharged, after being examined by a neurologist and a cardiologist. When they leave, her mother has instructions for the portable heart monitor Clara will wear for the next 24 hours and plans to schedule an EEG and a follow-up visit. The McNeelys get home only minutes ahead of a dozen little girls invited to sister Ella’s 6th birthday party.
While she frets about Clara, Tyler McNeely rates the care her daughter received as “great” and says she’s more than satisfied with the health insurance the family has through her husband’s concrete business. The debate in Washington “does worry me,” she says. “We’re just happy with what we have, and I’m scared a change will make it worse.”
9 a.m. Monday: The rhythm of the day
There is a rhythm to the day in the emergency room. When O’Connor took over at 7 a.m. Monday, there were 13 patients being cared for in the ER. Chris Holstege, the attending physician going off duty, and a half-dozen residents gathered around the central desk for a quick rundown on each patient as they are handed off to O’Connor’s team.
The volume of patients arriving for care generally starts out slowly in early morning, then picks up about 9 a.m. as people who have felt ill all night trickle in. Next are some patients who called their primary-care doctors when offices opened Monday but found they couldn’t get appointments anytime soon. If their complaint sounded serious, some were told to go straight to the ER.
By late afternoon, the steady stream of patients includes adults who tried to finish their workday before dealing with ailments and parents who came home from their job to find a sick child needing medical attention.
In all, 197 patients will arrive during this 24-hour period, from a 21-year-old woman seeking a pregnancy test (she’s not) to a 50-year-old man who arrives by ambulance with abdominal pain. A CT scan reveals that he has a perforated colon; hours later he is on his way to surgery. Most of the patients walk in through the ER’s double doors, but 61 arrive by ambulance, two by helicopter and two by police car — one each from the Fluvanna Correctional Center for Women and the Albemarle-Charlottesville Regional Jail.
The numbers peak from 2 to 3 p.m., when 22 patients check in at the reception desk. From midafternoon until midnight, there will be more patients than the facility’s 59-bed capacity. Leilani Herzog, 18, figured out the schedule the hard way. She and her mother, Susan Herzog, had come to the ER Sunday evening and waited for two hours before deciding to return the next morning, when they assumed things would be less hectic. (While the hospital sees some UVA students, most of its patients are drawn from Charlottesville and surrounding communities, including the most serious cases transferred from nearby regional hospitals with fewer resources.) They had flown from their home in Palo Alto, Calif., four days earlier for Leilani’s freshman orientation at UVA. By the time she got off the flight, an angry-looking skin condition was erupting on her legs and arms. When it got worse, they decided to go to the emergency room.
Susan Herzog hoped to figure out what was happening before she was scheduled to leave her daughter at midafternoon for the flight back to California. At 9 a.m., O’Connor and Crabtree puzzle over the inflamed-looking skin — none of the usual possibilities seems to fit the symptoms — and arrange for her to see a dermatologist. Leilani’s mother later reports that it is diagnosed as an autoimmune disorder that might have been triggered by a mild case of mononucleosis her daughter had sometime back. The Herzogs say they’re forced to be strategic in seeking care. They belong to an HMO in California, but Leilani is in an interim period until her “guest membership” in a Virginia HMO begins in 30 days. During that time, her insurance will cover just one ER follow-up visit. She had waived UVA student coverage to save the $2,000 premium on top of tuition and other college costs.
“We chose the HMO because the co-pays were better, and my payment was less through my employer,” says Susan Herzog, 49. What’s more, the other insurance plan she could have chosen wouldn’t have covered pre-existing conditions. A nurse, she is employed by a biotech company to work with cancer patients who are having trouble getting coverage for the oncology drugs the firm has developed. She and her daughter appreciate the savings from the HMO but aren’t always happy with the quality of care. When she had a sinus infection last year that required surgery, “I was on the Internet, trying to figure out what was going on,” Susan Herzog recalls. “I felt the onus was on me.”
When it comes to changing the health care system, though, she is ambivalent.
Despite her complaints about the HMO, she prefers private insurance because she fears a government-run plan would limit her choices. On the other hand, “there are a lot of kids and low-income families that aren’t insured,” she says. She’d like them to have coverage.
“But wouldn’t it raise your taxes?” her daughter says. “You’re always worried about that.” About 30% of the patients who use the UVA emergency room in a year have private insurance; another 40% are covered by Medicare, the federal program for seniors, or Medicaid, the federal-state program for the poor. More than one in four are categorized as “self-pay” — that is, uninsured.
Nationwide, 40% of emergency-room patients have private insurance and 17% are uninsured, according to a study released in July by the Robert Wood Johnson Foundation.
At a desk tucked in a corner of the ER, Erlinda Skeen is meeting with patients who are ready to be discharged. For those without insurance, she calculates what they owe for the visit, from $6 for the poorest to $426 for the most affluent. The hospital caps overall treatment costs for low-income patients on a sliding scale.
Skeen encourages those with outstanding charges to work out a payment plan with the hospital, but some struggle even to produce the $6 minimum. “They are sick,” she says. “They have no money, no job.”
3 p.m. Monday: ‘May God help’
Jose Vasquez, 76, is one of those without insurance, here or in his native Honduras. He divides his time between the Central American nation and Northern Virginia, where two of his five grown children live.
Four days earlier, he lost control of the left side of his face, his cheek drooping and his eye tearing, unable to blink. His daughter, Sandra, drove two hours to the Charlottesville hospital because her family thinks it offers better care to the uninsured than hospitals closer to her home in Woodbridge.
Her mother has been a cardiac patient here for three years. It is her father’s first visit. They walk through the main entrance at 3 p.m., during the busiest period of the day. The waiting room is nearly full of patients and family members. On a computerized map that allows staffers to monitor the ER at a glance from their laptops, every bed is marked with the name of a resident and accompanied by symbols that indicate what tests have been ordered.
By 5:15 p.m., Vasquez, a small man in a worn canvas cowboy hat, is sitting on one of the 18 hallway beds used when there’s a crowd. His daughter-in-law, Claudio Castro, has helped translate to and from Spanish as he is seen by a nurse, a resident and then the attending physician.
Burt, the doctor in charge, returns with a diagnosis: Bell’s palsy. Speaking in Spanish, he explains that a facial nerve has become paralyzed, a condition that isn’t dangerous and usually gets better on its own within a few weeks. He emphasizes the importance of keeping the eye moist, even at night. Otherwise, he warns, it could dry out like a fish’s eyeball left in the sun.
He suggests Vasquez wear a patch over his left eye until he’s able to blink it again and gives him a prescription for eye drops. Vasquez owes $6 for the visit.
“May God help finance the costs of those of us who have nothing,” he says, gratefully. One of the fundamental goals of this year’s push on health care — and of efforts launched by President Clinton and Harry Truman— is extending coverage to every or almost every American. (Vasquez, a foreigner visiting on a visa, wouldn’t be covered under the proposals.) The ranks of the uninsured, estimated at 46 million in 2007 by the Census and believed to be higher now, complicates health care and sometimes overwhelms emergency rooms. Under a 1986 federal law, hospitals must treat everyone who shows up and needs care, regardless of their coverage or ability to pay. (Emergency rooms are allowed to divert ambulances elsewhere if their beds are full.)
The task is expensive.
Those who lack insurance often don’t have the means to pay the bills themselves, so their costs are sometimes shifted to those who do have insurance. The state of Virginia reimburses the UVA Medical Center $70 million a year for charity care, says Larry Fitzgerald, a financial officer with the health center, but that’s short of the $80 million cost of the charity care the hospital provides.
”It’s like being a dishwasher when you work in the ER: They just keep coming,” says Jonathan Bartels, a nurse for 12 years and an orderly before that. He has elaborate tattoos on his right arm and an easy, down-home rapport with patients. “We cannot close. We cannot turn away. Whatever comes through that door, we have to care for.”
“A decent number of folks who come to the hospital ought not to need to come here,” says Jon Howard, 40, a nurse who also volunteers as a paramedic. “We have patients who have a known diagnosis of seizures who are out of seizure medication. Since he doesn’t have insurance, he doesn’t have a doctor, so he comes to the emergency department for routine prescriptions. It’s wildly inefficient.”
The uninsured tend to use the ER in a different way than those with insurance. About half of those who come to this emergency room with insurance are admitted to the hospital for conditions too serious to be treated as an outpatient. For those without insurance, however, three in four are treated as outpatients. That suggests they are using the ER for more routine care.
Because the emergency room is staffed 24 hours a day and maintains an array of high-tech equipment, a typical patient visit here costs more than one to a primary-care doctor. Treating a serious headache at UVA’s primary-care clinic costs an average of $232; in the emergency room, the tab more than doubles.
The costs are more than financial. Because those without insurance often don’t have a source of primary care, they get little preventive care and can delay treatment for a minor problem until it becomes a major one.
“Instead of coming in with a simple toothache, they’ll have a dental abscess,” says O’Connor, 52. The chairman of UVA’s Emergency Medicine department, he has red hair, a ruddy complexion and a reassuring mien. “Or a patient comes in with high blood pressure, and they’ll have evidence of renal failure. They’ll present (themselves as a patient) out of desperation.”
There are those “who, in an effort to save money, won’t go to the doctor, like that guy who had a heart attack today,” says Burt, a slender man with a smooth pate. He is referring to the 35-year-old logger.
5:15 p.m. Monday: A roadside rescue
Roger Burke’s EKG arrives at the hospital before he does.
Cindy Garrett and Jennifer Alexander, EMTs for the Madison County emergency services department, had been sent to meet Burke at Jag’s Market & Deli in Brightwood, Va. Burke’s boss was driving him there to rendezvous with the rescue squad from a forested area where they had been cutting trees.
Still parked in the lot of the gas station-convenience store, the emergency medical technicians take an EKG (also known as an ECG) in the back of the ambulance. It shows Burke is, in fact, having a heart attack. They fax the results to the UVA emergency room and begin the 35-minute drive there.
At the hospital, “we went ahead and called the cath lab and said, ‘We got a hot one coming in,’ ” Burt says.
During the drive, Burke goes into cardiac arrest. The rescue squad pulls to the side of Route 29 and stops, and the EMTs use a defibrillator to shock his heart back into a steady rhythm.
When they get to the hospital, Burke is conscious but pale and prone on a stretcher, his pack of Marlboros and bottle of soda still tucked next to his legs. Garrett and Alexander wheel the gurney down the hall and into a resuscitation bay. A team of doctors and nurses is waiting to take over.
Garrett looks tired, relieved and proud as she pauses in the emergency room for a few minutes. An EMT for seven years, she says she has found her calling. “This is my career forever,” she says. Besides working 40 hours a week for Madison County, she volunteers an additional 13 hours a week with the Charlottesville-Albemarle Rescue Squad.
As for changing the health care system, “I’m not really into the political part of it,” she says, although she has had personal run-ins with the current system. Madison County pays the full costs of her health insurance, but the family plan that also would cover her three children would cost her more than $600 a month. The kids are on Medicaid instead.
Her daughter has Type 1 diabetes, but Medicaid refused to pay for a state-of-the-art insulin pump. The premiums strained the family’s budget, but Garrett added her daughter to her insurance plan for a year so she could get a pump.
”She was 2 (when) we began dealing with all of this,” she says. “It wasn’t until she was 5 that she got the pump,” a situation Garrett still finds infuriating. Now her daughter is 9, and Garrett wants her to have an up-to-date sensor for the pump. “I’m figuring out how to get that,” she says.
11 p.m. Monday: Coming back around
The last time Washington debated big changes in health care, Chris Ghaemmaghami was graduating from the University of Miami medical school. “In 1993, everybody was talking about health care reform,” he recalls. “I sized up: ‘What’s always going to be needed?’ ”
He decided to specialize in emergency medicine and internal medicine, on the theory that the proposal being advanced by the Clinton White House task force would increase the need for primary-care doctors. Now 39, he is an attending physician at the ER. His wife is an oncologist.
Clinton’s plan collapsed in Congress, but “you knew it was going to come back around,” says Ghaemmaghami — pronounced “GUY-um-MAG-um-ee,” although many folks at the hospital simply refer to him as “Dr. G.” On this day, his shift starts at 11 p.m. “I do think major aspects of the system need to be altered because we’re in an unsustainable system right now,” he says.
Ranking state and local political leaders in this area generally agree on the need for change. Virginia Gov. Tim Kaine, Sens. James Webb and Mark Warner and the local congressman, Tom Perriello, are all Democrats. Perriello, who defeated six-term Republican incumbent Virgil Goode last year in an upset, held 21 town-hall-style meetings in the 5th Congressional District during August, many dominated by the health care debate.
Even so, few of those interviewed in the ER have much idea of even the broad outlines of what’s being considered in the House and Senate. In a sobering sign for Obama and congressional Democrats, what has broken through more clearly are warnings from opponents that congressional action is likely to raise their taxes, limit their choices, increase their waiting times and lead to “socialized medicine.”
”I hope they do something to help the elderly and the people who can’t afford insurance, people who don’t have primary care because they have no funds,” says Belinda Williams, 55, who has an overnight shift in the ER, registering patients and drawing blood. Even so, she is anxious about what she has heard about a government-run plan.
“You have a lot of insurance companies that are competing now,” she says. “If you get lumped into one big group, I think it’s going to cost more.”
3 a.m. Tuesday: More than heartburn
Twelve hours earlier, Roger Burke, the logger, had been on the job.”I was cutting trees, and I started sweating,” he says, recounting the day. “There was pain down my left arm, pain throughout my chest, just a lot of painful pressure.” At first, he thought his ulcer might be acting up, or maybe he had developed a bad case of heartburn. When he connected with the EMTs, they confirmed his worst fears: He was having a heart attack, just like his dad. “They began medicines and IVs and what-not,” he says. “But three-quarters of the way here, they lost me.”
He says everything went white and silent as he went into cardiac arrest. The next thing he remembers is the two women shouting his name and asking him questions. They had restarted his heart with a shock from a defibrillator. “They definitely deserve congratulations,” he says.
Now he is lying awake in the hospital’s cardiac care unit — a clot found in an artery, a stent inserted to keep the artery open and his life turned upside down. Burke is a plain-spoken man with close-cropped, sandy hair. His father and grandfather died from heart attacks, his father at age 50. Although Burke hadn’t had heart trouble before himself, he has worried about it, given his family history. With no health insurance, however, he hadn’t done anything about it.
“Going to the doctor is bad enough, but getting the bill is murder,” he says. “If you aren’t dead, you might wish you were.” At one time, he had health insurance through his wife, a certified nurse’s aide, but when she changed jobs, they lost their plan. The couple is separated now. Thinking back, he says, he had been feeling lousy for weeks. Then it got much worse the previous day. “If I had health insurance, I would have come in a whole lot sooner,” he says. Burke is skeptical that policymakers in Washington will be able to make things better for people like him. “I don’t see how it’s possible, frankly — how a health care plan can be affordable to everybody,” he says. “Somebody’s got to pay.” For now, he is trying to figure out how he’s going to afford the medicine the doctors have told him he’ll need to take, much less the bills he has racked up in the past few hours. He has no idea what they’ll total. He also realizes that he won’t be able to go back to his job for a while. “I know it’s going to be very expensive,” he says. “But how do you put a price tag on living or dying?”
5:50 a.m. Tuesday: ‘I’ve got nowhere to go’
Lewis Newman is wheezing as he walks into the ER, struggling to breathe. Somehow the heat in his apartment was turned on this muggy August morning, circulating dust and pollen and triggering his asthma. He used to have an inhaler, but can’t find it. Forty minutes later, the 45-year-old part-time laborer is lying in an ER bed, holding a mask to his face and inhaling a mist of medicine from a bedside nebulizer. “I just couldn’t get my air going, but I’m almost back to normal now,” he tells Megan Koontz, 28, a third-year resident. Newman is a regular visitor to the ER. When Ghaemmaghami, the attending physician, walks in to check on him, Newman says: “I know you!” — from a visit six months earlier, he says, for an ailment he can’t recall. At 6-foot-4, “Dr. G.” is an easy figure to spot.
By 7:30 a.m., Newman is discharged with a prescription for an inhaler. He isn’t insured, but isn’t concerned. “I’ll find a way” to manage, he says, now breathing easily. “No hurry,” he tells the nurse as she fills out paperwork. “I’ve got nowhere to go.” Meanwhile, Ghaemmaghami is back at the main desk, running through the ER list with Stephen Huff, the attending physician who is coming on duty. Eight residents cluster around the desk. Some offer a quick rundown on the patients they have been tracking. There are 20 patients in the ER. Another shift is about to begin.
