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Old 07-16-2008, 02:33 PM
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Default When the bottom line overrides the Hippocratic Oath

When the bottom line overrides the Hippocratic Oath

As a pediatric resident, I couldn't believe it when the surgeon called back and said we don't treat those kinds of patients.
By Rahul K. Parikh, M.D.
Jul. 16, 2008

I don't remember many specific patients from my days as a resident. Like all doctors in training, I was overworked, underpaid and chronically fatigued. With that, details become murky.
What I do remember, though, are certain incidents that gave me pause and made me wonder what the hell I had gotten myself into. The kinds of situations that only residents -- who are the blunt business end of America's sloppy healthcare system -- can get stuck in.
Take my experiences in a Los Angeles hospital with kids who needed a surgeon. I would be on call, living in scrubs, trying to digest hospital chow. In the dead of the night, my pager would begin squealing, jarring me awake (if I was lucky to sleep in the first place). A number from an outlying hospital would flash on the screen. Stumbling out of bed to the nearest phone, I would learn that a child with, say, an open fracture of his leg needed to be transferred to our hospital since we offered "a higher level of care," which often meant an orthopedic surgeon who could treat the child.
Indeed, this is what happened one night. With the child on the way, I paged the orthopedic surgeon on call. Surgeons like information given to them concisely and directly. I ran through what I would say: "Sorry to wake you, Doc, but I have a 5-year-old male en route from a community hospital who has an open fracture of his right femur. According to the transferring physician, he will need to have a reduction in the operating room tonight. While we're waiting for you, we'll start morphine for pain relief and some Ancef (an antiobiotic) for infection prophylaxis." Then I waited for the phone to ring.
When the surgeon, a partner in a private Beverly Hills orthopedic group, returned my call, I was naive enough to expect some further questions about the child's history, requests for some laboratory work or more X-rays, and instructions on how to prep the operating room. Instead, his first question was: "What's their insurance?"
Medical students and residents are trained to anticipate and prepare for a lot of things. If we're doing rounds with a senior physician, we try to be prepared for questions about the illnesses of our patients and how to treat them. For those reasons, and for our love of learning, many of us would talk about our patients and read in advance of our rounds, even when we could have been sleeping.
But I was not prepared for this question. I told the surgeon I would call back with the insurance information, which forced me to call the transferring doctor. I can't remember if the child was underinsured, uninsured or was insured by the state, but it didn't matter. When I called the surgeon back, he refused to come in. His group didn't cover "those kinds" of patients.
So there we were -- me, my intern, a nurse -- somewhere between late at night and early in the morning, alone. A broken child and his parents were on their way in an ambulance. We had promised to provide "a higher level of care," but the only doctor who could give that care just killed it. What was my plan? I was the doctor, after all. I had no idea.
In the end, all we could do was give the child morphine (a lot of it) and antibiotics, hoping we could keep him comfortable. Still, every time he moved just a little, he howled in pain. We hoped he wouldn't lose his leg to some flesh-and-bone-eating infection. And so we waited until morning, when we would ask our teaching attendants to delicately negotiate with the surgical group to please come in and take a look.
What did I learn that night? Certainly nothing about the preoperative and postoperative management of children with femur fractures. No, I learned how even in the dead of night, in the presence of a child suffering, the bottom line can override the Hippocratic Oath.
Such is our peculiar institution called American healthcare. We have gobs of money, the best technology, plenty of specialists, and spend the most money on healthcare in the world. Despite that, a child gets left out in the cold. Whom do we blame? Some would say the surgeon for refusing to play ball. But practically speaking, would you, whatever your job, work for free? In some cases, you can hold patients accountable for being careless with their health -- drinking, smoking, eating too many McNuggets -- but you can't prevent unforeseen things.
This is especially evident in pediatrics where children will suddenly develop epilepsy or leukemia, or have an accident. You can blame insurers for their reimbursement games, the American Medical Association for lobbying to maintain the status quo, lawyers for bringing frivolous lawsuits, or drug makers for blocking international imports to keep prices high. The list goes on and on. But in the end, put it all together and it's a system, a monstrous medical-pharmaceutical-legal-actuarial-industrial complex that's leaving a lot of people behind.
There are triumphs to report. But those often refer to the most fortunate. Take the celebrity mother who went into preterm labor at 35 weeks during a transcontinental flight. She was wheeled into a private hospital room (off limits, of course, to residents), where her private doctor and two neonatal ICU specialists were waiting for her. I was called in a couple of days later and found a very large, intimidating dude standing at the door, checking the IDs of everyone who went in and out. He was the celebrity mother's bodyguard. While the baby was there, his pediatrician, a 90210 doctor type whose signature wasn't his clinical acumen but his Tommy Bahama shirts, checked the mother twice a day.
But healthcare, unlike caviar and first-class airline tickets, shouldn't just be for rich patients and their doctors. So enough already. Let's fix this mess. Get people insured, get incentives aligned, use technology to be more efficient and effective. Stop relying on market forces, stop backing the status quo, give people, rich or poor, access to quality healthcare. It won't be perfect. There will be challenges, the most important one being that we will have to confront the fact that we're trying to do unlimited things with limited resources. But we need to level the playing field, not only for the next child with a broken leg, but for the overworked, underappreciated staff of doctors and nurses who commit to taking care of him in the middle of the night.

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Old 07-16-2008, 04:21 PM
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I'd post a reply, but the subject just pisses me off in general, and anything I say might get me bleeped, banned exiled, or possibly eliminated, in one way or another. :mad:
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Old 07-16-2008, 11:24 PM
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Me too - nobody is a VIP because they all should be!!! Gets me fired up too!
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Old 07-16-2008, 11:54 PM
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Nice thing about EMTALA......if a pt is transferred from an ER, the tertiary care canNOT refuse based on finances. The pt is considered to not be medically stable since the first hospital is unable to complete the needed care. Don't know when that article was written, but in recent years that would be inviting a HUGE fine from EMTALA.

I have watched as my rural ER docs would fight on the phone with specialists at higher levels of care who tried to refuse pts for various reasons. The one question that would always get them to back down was "So you are refusing this pt?" A "yes" would have been an immediate EMTALA and would have been reported.
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Old 07-17-2008, 12:06 AM
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Quote:
Originally Posted by Poliopioneer View Post
I'd post a reply, but the subject just pisses me off in general, and anything I say might get me bleeped, banned exiled, or possibly eliminated, in one way or another. :mad:
Why would you be banned? Say it!
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Old 07-17-2008, 12:08 AM
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Thankfully that can't happen here. Someone walks through our hospital doors, and they are entitled to treatment. Mind you most of our hospitals are public. Not quite sure what would happen with a private hospital, but I do know, that unless you request or present at a private hospital, you would go public.

BTW, whats EMTALA
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Old 07-17-2008, 02:02 AM
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EMTALA is an emergency treatment law that states that a patient cannot be refused care when they are unstable medically, regardless of their ability to pay. When they are stable, they can be tramsferred, but until then, the hospital is obligated to stabilize them.
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Old 07-17-2008, 02:10 AM
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That makes my blood boil too!!

I feel so sorry for that poor doctor and nurses, to have to face the parents and say well, no we are not going to operate on your child tonight even though you were told we would and the child is in considerable pain....

As Jay said, our hospitals are public hospitals, so everyone gets treatment there for FREE, no insurance needed. You do also have the choice to go to a private hospital if you wish though.

Sorry Americans, but your healthcare system stinks!!
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Old 07-17-2008, 02:59 AM
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I hate to say it, but I agree. Our health care system is broken and needs to be fixed!
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Old 07-17-2008, 07:50 AM
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Quote:
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EMTALA is an emergency treatment law that states that a patient cannot be refused care when they are unstable medically, regardless of their ability to pay. When they are stable, they can be tramsferred, but until then, the hospital is obligated to stabilize them.
Yes, and until the pt has been treated for the emergent problem the pt is not considered stable. Medically stable to withstand the trip, yes, but not medically CLEARED. The only way a hospital can refuse a transfer is if there are no beds open, or if the specialist on call would be delayed to the point where the pt could have a negative outcome .
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