Flatlined: Resuscitating American Medicine

Chapter 2. Unreliable Emergency Services

10 In the late 1970s, I was a resident physician training in a public hospital. My colleagues and I had become furious at groups of neurosurgeons in two Texas towns who often referred to us patients with problems that they said were too complicated to manage in their hospitals. Hours later, we would go down to the emergency room to receive some poor soul who was often medically unstable and had been transferred at his peril only because he lacked health insurance and could not pay. These abuses became so outrageous and widespread that the media took notice and alerted the public, which was shocked. A woman in active labor whose fetus did not have enough oxygen was dismissed from the emergency room of a private hospital and told to go to a county hospital across town, where her baby died because of the delay in care. An injured patient bled to death after the emergency room of a private hospital transferred him in shock with low blood pressure to a county hospital only because he was uninsured. But these were not isolated stories.1 This so-called “dumping” of uninsured patients was a widespread practice before the Emergency Medical Treatment and Active Labor Act (EMTALA) was signed into law in 1986. EMTALA ended these practices by forbidding hospital personnel from even inquiring about insurance in an emergency situation and prohibiting hospitals and doctors from refusing emergency care to anyone at all. In a properly handled emergency, no one has time to ask about insurance, and the information is often not available anyway. We all look alike when we are injured, undressed, and covered in blood. 2 Unreliable Emergency Services The public should not look to the medical industry or to organized medicine for leadership in solving medicine’s problems. CH002.qxd 10/7/08 9:47 AM Page 10 UNRELIABLE EMERGENCY SERVICES 11 EMTALA has two qualifiers that relieve the doctor and the hospital of responsibility for emergency care. A hospital is only required to accept patients who have an emergency if it has the capability and the capacity to deal with that emergency. Capability means that if the hospital provides the service on a regular basis, it must provide the service on an emergency basis. For example, if the hospital provides brain surgery during the day, then it must provide it around the clock. Capacity means that emergency patients must be admitted if the hospital has room but not if it is full. When hospitals are over capacity, they typically send out a diversion signal to notify ambulances that they cannot take any more patients. Simultaneous diversion signals from every major hospital in the region doomed the woman from Lake Jackson to end her days in a nursing home, vegetative and tube-fed. Federal law makes an important distinction between emergency and non-emergency care. No hospital or doctor is compelled by law to provide care to a patient with a medical problem that is judged by medical personnel not to be an emergency, defined as a condition that, if not treated promptly, is likely to place the patient in serious jeopardy. Routine medical care of the uninsured is rationed and isolated from routine care of the insured. For emergencies, however, there can be no distinction, a situation that has led to a growing problem for all members of society. More Preventable Deaths By 2001 Houston and San Antonio trauma centers were on diversion 30 percent of the time, with the problem becoming steadily worse. The day after Halloween in 2001, I got a call from a neurosurgeon of long acquaintance . Had I heard about Bill Huntsman (not his real name)? He was a twenty-one-year-old man from Katy, a bedroom community near Houston. On Halloween night in the early evening, Bill had left work and was walking home along the edge of a busy road. A car swerved and hit him from behind. Unconscious and badly broken up, he was taken by ambulance to nearby Katy Memorial Hospital, a small community hospital with eighty-eight beds and an emergency room more accustomed to treating stomach pain, asthma attacks, and broken noses than lifethreatening trauma. CH002.qxd 10/7/08 9:47 AM Page 11 WHY THE UNINSURED SHOULD BE COVERED 12 The mnemonic for the priorities of trauma care is ABC: airway, breathing, circulation. That is, make sure that the airway...