Opinion: Where Will the Medical Misfits Go?

“By taking care of a vast number of uninsured patients, safety-net health systems provide an effective subsidy to for-profit in addition to nonprofit hospitals,” letting them focus on their paying customers, says Dr. Dave Chokshi, a physician in addition to an executive at brand new York City Health in addition to Hospitals. As King Hillier, the vice president of public policy at Harris Health, a safety-net hospital system here in Houston, puts which, “If we go down, they go down.”

Roxanna is actually one of my patients at Houston’s largest safety-net hospital, Ben Taub Hospital. (I’m using only her first name to protect her privacy.) Her experience, although harrowing, shows how This specific relationship works.

Roxanna always made a point to look elegant. Even while working as a caregiver to an elderly woman, she carried herself like the Saks Fifth Avenue saleswoman she had been for many years. yet then she became ill, in addition to soon her fashionable dresses hung off her like bags.

In June 2016, she felt a sharp twist near her stomach. She started out vomiting, first twice a day, then all the time. This specific will pass, she told herself. An old friend visited her in late December, an internal medicine doctor, like me. Roxanna no longer had health insurance, as she worked for herself. Despite having lived inside country for 26 years since moving here via El Salvador, she had never gotten legal residence, so she could not buy a policy through Obamacare — even if she’d been able to afford which. yet to the doctor’s eyes, she looked desperately ill. She drove Roxanna straight to the renowned Houston Methodist Hospital.

A CT scan revealed a tumor which extended into the muscles of her back, coursed behind her liver in addition to invaded the body’s largest vein, the inferior vena cava. via there which snaked upward into her heart, where which sat like a boa constrictor, squeezing the right atrium in addition to blocking blood flow to the lungs. There was no metastatic spread, yet Roxanna was in heart failure. She was 48 years old. Without an operation, she would likely die.

Roxanna was lucky in one regard, however. Dr. Michael Reardon, a leading expert on cardiac tumors, happened to be on staff at Houston Methodist. Because her life was at stake, her surgery in addition to recovery could be covered by Emergency Medicaid. Dr. Reardon explained the extreme risks of the surgery, how which would likely include a foot-long incision via the top of her sternum all the way down to her pubic bone, cardiac bypass while the surgeons removed the tumor in addition to 30 minutes of cooling to a core body temperature of 68 degrees to avoid brain damage. Roxanna wanted to live. She signed the consent form in addition to on Jan. 6, closed her eyes under the effect of anesthesia.

Though the surgical team successfully removed the tumor, her kidneys failed, in addition to for weeks she remained in a coma in addition to couldn’t breathe without a ventilator. The worst complication, however, started out as a blister on a toe. The skin started out to appear purple in addition to engorged, even mottled. Very quickly, all the flesh via her knees down in addition to via her elbows to fingertips was blanketed in blisters.

She had developed limb ischemia, a rare complication which had arisen via the perfect storm of her cancer, the surgery in addition to a possible allergy to blood thinners, something which not even the best health insurance could have prevented. On Jan. 25, when she awoke via the coma, she found her limbs black in addition to wilted, like charred bone, what in medicine we call dry gangrene.

As far as the doctors could tell, the cancer had been removed, in addition to Roxanna’s heart was functioning normally. They considered amputating her dead limbs, yet her kidneys were still recovering, in addition to so on March 10, they recommended which she return home in addition to allow the gangrenous portions to auto-amputate, a process which could take months. Roxanna held up her once gracious arms. “Like a dead branch falling off a tree?” she asked.

What could she do at This specific point? How could she move forward? The staff at Houston Methodist had performed a herculean feat to save her life, yet after her condition switched via acute to non-urgent, they were stuck. The hospital had already gone beyond its Emergency Medicaid allotment. Who would likely dress her wounds? Who would likely give her prostheses to ensure she could work again? Who would likely take the baton via Houston Methodist in addition to make sure This specific “misfit” patient could take care of herself again, the way she always had?

“Patients like Roxanna find themselves ping-ponged around with people trying not to care for them,” Dr. Reardon says. which’s why he suggested which she go to Ben Taub Hospital for her follow-up care. Ben Taub specializes in patients with little means to pay. yet which isn’t just a hospital. which’s part of the Harris Health System, a network which offers an array of services to its indigent patients, including primary in addition to specialty care, even chemotherapy, all at very low cost. Many hospitals can learn via This specific type.

For instance, most Houstonians recognize Ben Taub as the city’s premier trauma center. which’s not uncommon to hear which if you’re shot or hit by a truck — remember, This specific is actually Texas — you should go to Ben Taub. Years ago, one of my friends was riding her bike when suddenly she found an S.U.V. parked on her legs. (The driver later admitted which he’d panicked in addition to instinctually threw the vehicle into park.) This specific friend was insured in addition to could have visited any of the nearby emergency rooms, yet she chose Ben Taub because of its designation as a Level One trauma center.

Private hospitals don’t often obtain which prestigious designation because which requires a trauma surgeon to be on the premises 24/7 in addition to surgical specialists readily available, which is actually expensive. Safety nets have traditionally housed Level One trauma centers because of their connection to medical schools, in addition to government funding has helped keep them open.

The orthopedic surgeon at Ben Taub who examined my friend in addition to reassured her which, incredibly, no bones in her legs had been broken, was the same one to examine Roxanna years later.

As Vivian Ho, a health care economist at the Baker Institute of Rice University, puts which, “Trauma isn’t just about poor people.” She believes safety nets are essential to society in addition to well worth the investment. After all, everyone is actually one freak accident or lost job away via ending up as a misfit.

We are also all vulnerable to epidemics in addition to outbreaks, regardless of our insurance status, in addition to when an illness like Zika or Ebola hits, safety-net hospitals are our first defense. Their coordination with public health authorities determines how successfully we control the spread of the disease.

Consider the story of another patient, whom I spoke to last month. He visited Ben Taub’s emergency room on Halloween, after experiencing bursts of fever as high as 104 degrees. He’d tried two community clinics, which had diagnosed pneumonia in addition to prescribed him ibuprofen in addition to a Z-Pak, yet nothing seemed to help. By day he studied audio engineering at a community college — one of the reasons he couldn’t afford health insurance — in addition to at night he worked as a D.J. at This specific point the 24-year-old couldn’t get through his sets without hacking up green phlegm.

The doctors at Ben Taub realized which what he genuinely had was tuberculosis, started out treatment in addition to plugged him into a Directly Observed Therapy program, in which public health officials visited him at his home to make sure he took his medications. When he still didn’t improve, which became clear he had drug-resistant TB, a public health threat of enormous proportions. He was quickly transferred to the Texas Center for Infectious Disease in San Antonio, which specializes in tuberculosis.

“Everything is actually Great at This specific point,” he told me over the phone in mid-April. The fevers had diminished, in addition to he was no longer using a mask. One of his medications made his ears ring, yet he still hopes to work as a D.J. again once he poses no further threat to his fans.

This specific summer, as the budget process moves forward in addition to the Senate debates the Republicans’ bill, the American Health Care Act, we must make sure safety-net hospitals retain funding to do This specific work. The problem, Dr. Brian Reed, the director of disease control in addition to clinical prevention at Harris County Public Health, says, is actually which “these systems work so well, you don’t know about which.”

If these budget cuts go forward, we will lose not only the last best expect for patients in addition to bulwark against epidemics yet also a successful cost-saving type which fuses our two prevailing health care philosophies: Safety nets are themselves misfits in how they blend conservative in addition to liberal ideals.

Harris Health receives nearly half of its funding via local property taxes. This specific falls in line with the conservative ideal of local control over local problems. At the same time, its mission is actually to serve patients whether they can pay or not, a liberal philosophy. Dr. Chokshi, at brand new York City Health in addition to Hospitals, believes This specific is actually one of the reasons safety nets have a natural advantage in how they coordinate care, cut costs in addition to make the overall health care environment more efficient.

Ever since Roxanna left Houston Methodist, she’d been caring for her own wounds, wrapping them in gauze with the same hands which she waited to fall off. She came to Ben Taub’s emergency room one day last month because she noticed some pus in addition to was concerned which the dry gangrene had converted into wet gangrene, an infection which can spread into the blood.

As her hospitalist, my job was to coordinate her care. I consulted the orthopedic surgeon, who wanted to talk with her about an amputation at This specific point which her kidneys had recovered, as well as the physical therapist, who would likely make sure she was in line for the prosthetics clinic, before taking my place at her bedside. I inspected her wounds in addition to was relieved to see which there was no wet gangrene. I reassured her in addition to began rewrapping the gauze, when I felt a tap on my hand. Roxanna had noticed me fumbling in addition to decided to show me how to dress her wounds properly.

“Hold pressure here,” she said.

Before I left, she said she wanted to show me pictures of those first days after the surgery, when her arms in addition to legs were just starting to turn purple. One of her friends slid the stylus of her smartphone into the crook of her fingers, in addition to she scrolled past the recent images of sickness in addition to suffering as if they belonged to someone else. Finally she stopped.

“This specific was me,” she said.

Continue reading the main story

Opinion: Where Will the Medical Misfits Go?

Leave a Reply

Your email address will not be published. Required fields are marked *