DWXXV
· 21 days ago
Sometimes I complain how healthcare costs in the U.S. are poorly understand by...pretty much everyone. It goes beyond "doctors get paid too much" "socialized medicine will fix/break everything" "drug companies are greedy."
if you have any understanding of business half of what goes on in the hospital is going to be insane to you.
The following patient is not a specific patient, he is a combination of patients I've seen and heard about over the years. Sadly none of this is fictitious:
-On a cold spring morning a patient is brought in by EMS, he was found down on a street corner, by his appearance and location he is clearly homeless, he was partially in the street so the police are involved and EMS calls a trauma in case he got hit by something.
-He is hypoglycemic, hypothermic, and clearly fucking wasted. The residents run a trauma. Registration starts getting annoyed because the patient has no possessions (other than his clothes which were cut off and binned) and they have zero clue who he is. The attending is ex-military and actually has a good relationship with the police so he gets them to help. They go back to the scene and find a shopping cart with a bunch of crap in it including a Guatemalan ID card. The name is hilariously generic (from now on: Jose).
-The resident finishes resuscitating the patient but he still isn't awake, alert, and oriented. The attending calls the MICU screener because he figures this patient is going to start crab walking along the ceiling as soon as he starts going through alcohol withdrawal and will need a drip. The screener arrives, she's on hour 22, had four people die on her last night (and therefore has open beds) and doesn't have time for this. They send Jose to the MICU. They also know this guy isn't going to pay for anything.
-Jose wakes up at around 2pm, he's very pleasant, seems totally fine (VSS), but insists his name is Daniel not Jose.
-The MICU senior resident looks to see which teams are taking downgrades right now, spots a resident on his shit list (literally - previously the guy wandered off during signout to take a dump and made the MICU senior stay an extra hour). Correctly reading that Jose is going to be a pain in the ass he downgrades him from the MICU to the medical teaching team with the shitty resident. Later the MICU senior will get yelled at for not sending Jose to a less expensive non-teaching service.
-Jose is seen by his new teaching service. He's confused. He sort of speaks English but sort of doesn't. He insists his name is Daniel. The intern (junior resident) insists he's just trying to get a warm bed and will leave as soon as he wants booze. The attending says she knows exactly what is going on and to call her after the team gets the labs to prove it (but doesn't say what those are). She walks off and goes to take a nap.
-At exactly the time of signout Jose tries to leave (per him: to go get more alcohol).
-Intern runs to try and get him to stay. While this happens the labs come back, the senior checks them and realizes what the attending was thinking - this guy has severe brain damage from chronic alcohol abuse.
-Intern is having no luck convincing this guy to stay in broken Spanglish. Senior, attending and three med students (who should have been sent home 3 hours ago) arrive. Patient starts to get agitated.
-The attending feels he lacks the capacity to make medical decisions for himself due to brain damage, so he can't leave. The residents remind the attending that the medicine team can make this determination but the attending insists they call psychiatry for a stat consult.
-Psychiatry is currently at home eating dinner. He is also 78 and mostly retired. It takes him 45 minutes to drive to the hospital due to the tail end of rush hour traffic and an accident on the highway. He arrives at the hospital and speaks to the patient. "Whats your name" "Daniel" "Is your name Jose" "Si" "Is your name Daniel" "Si." The psychiatrist judges the patient to not have the capacity to leave AMA, goes home, and was paid 300 dollars for this unnecessary 30 second interaction. The next day he calls the intern and complains for 20 minutes about how they could have made the capacity determination without him. The intern knows this.
-The medicine team leaves three hours late.
-The next day they start working Jose up in earnest. They make him as healthy as they can but it appears the brain damage is irreversible. They also realize he has regular dementia. Over the coming days Jose starts refusing treatment because he wants to leave. Social work starts looking for next of kin. The nurses refuse to do anything no matter how many physicians say he doesn't have capacity. He starts to become mildly medically unstable. Apparently he was semi successfully taking his blood pressure medication on the street, but he refuses to take them in the hospital and the hospital won't force him to.
-Two weeks later he's about as medically stable as he was when he first made it to the floors (maybe worse) and no closer to discharge. Because he's on a high acuity medical teaching team he's seen by a resident, attending, and medical student every day...even though nothing happens and he is mostly incoherent for the interview. He is no closer to discharge.
-Nursing management calls a meeting with the ED, medical teaching team, and social work. ED doesn't know why they are there. Management yells at everyone for admitting this patient. The teams have turned over, none of these people admitted the patient. The ED attending reminds the admin staff that they would be legally liable if they hadn't admitted the guy and then leaves when the overhead calls out a trauma (however the trauma was fake, the ED just called it to rescue the attending).
-Social work recaps the situation. Jose can't make decisions for himself, he's an illegal immigrant with no insurance and no known family (at least in this country). As a result he has nobody to make decisions for him. They've reached out to the Mexican embassy to see if they can find any family in his home country. He can't be discharged to the street because it's not safe, so he'd need a charity spot at a long-term care facility. He also needs a court appointed guardian to make decisions for him because he can't accept a facility himself due to lack of capacity.
-The intern reminds social work that Jose is Guatemalan not Mexican. Guardianship paperwork is started.
-8 months later the court appointments a guardian. During this time he was seen by a resident, an attending, and a medical student every day. He had to be transferred to one of the few solo rooms due to increasing agitation. He spits at the nurses. He smears his feces on the floor.
-After another two months social work finally finds a charity care spot for him. However at this point he has medically destabilized - he's become altered and agitated again. Psychiatry is called.
-Psych talks to the patient for two hours, they call the primary team and tell them he's been under-stimulated in the hospital for so long that his brain has essentially finished rotting. He's now severely demented and belligerent. The best they can do is try and chemically sedate him long enough to con the accepting facility into thinking he's okay.
-They are not stupid. They don't take him.
-Jose dies in the hospital ten months later.
-Three months after that social work dutifully calls the medical team to let them know the embassy gave them the number of Jose's sister, she lives in town. The team has turned over, nobody on the medical team right now has any idea who Jose is.
Some of this is hard or impossible to fix. For example the way most hospitals handle teaching team assignments is basically the best possible way but that means you will have times where nobody has taken care of a patient before and they are being asked about decisions made months ago.
I don't know what the best way to handle this guy ethically is, but our current approach is almost maximally expensive. The hospital has to treat, and can't just get rid of the guy, even if he probably would have lived longer just drinking on the street. Hospitals can't say no. Rehab and other places can say no, even though they are orders of magnitude less expensive. Because this guy can't pay the cost is essentially passed along to the tax payer, and if enough of this guy come to the hospital the hospital dies (recently: Hahnemann).
Not every patient is as expensive as Jose (he's def top quality on that front) but the hospital is littered with unnecessary expenses like this and many of them aren't necessarily going to be fixed with single-payer.
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