- Taking Care of Our OwnIn Houston, undocumented immigrants have access to some of the nation’s best health care. Could this be a model for the rest of the country?
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It is june in houston and unseasonably dry, at least at 5:45 in the morning. Outside Ben Taub Hospital in the day’s first light, you can just begin to make out the forms of people sleeping on benches in the park across the street, patients still in paper scrubs who’ve been discharged but who have nowhere else to go. At this hour, inside the emergency room, the scene isn’t all that different. People lingering in the trauma center’s waiting room look less like anxious family members waiting for updates and more like passengers at a snowed-in airport. The blankets are out, CNN runs muted in the background, and anyone able to sleep does so across a row of vinyl armchairs. At one end of the waiting room, the triage nurse sits beside the vital-signs machine. Typically, I never see her. “Where are the ESRDers?” I ask, meaning the patients who are here because of end-stage renal disease. She sweeps her arm across the room. “Everywhere,” she says. “Where do we line them up?”
Things work a little differently now, she explains, as opposed to four years ago, the last time we worked in triage together: “A provider sees them with labs in hand, so that when 6C calls”—meaning the dialysis unit—“we can send them up.” She squints behind her glasses, either from fatigue or to look for the ER doc. “There she is.”
In a partitioned-off corner, the emergency-room doctor rifles through patient charts. I introduce myself to her tribally—“I’m internal medicine”—the way soldiers from different services might do in bunkers. She doesn’t bat an eye. “I work a lot with our undocumented patients,” I add, but still she says nothing. “I also speak Spanish.”
“Great,” she says, handing me a blue folder from her bin. “Sometimes I have trouble with the names.”
The first chart inside the folder is for a patient named Rogelio and lists “Disease Management F/U” (i.e. “follow-up”) as his chief complaint. As medical students, we are taught to use the patient’s own words—“My chest hurts!” “I can’t breathe!”—for this vital portion of the history. But this is emergency-room medicine, where the doctors are more interested in determining sick versus not sick than they are in the patient’s story.
Moreover, what has been written here isn’t a symptom; it’s code, a specific language used to designate Rogelio as an undocumented patient without coverage to pay for treatment of his chronic kidney disease. Patients like Rogelio who have lived in the United States for years but cannot qualify for federal funding through Medicare or Medicaid must visit emergency rooms, sometimes twice a week, for life-saving treatment. Because of this, cities with large undocumented-immigrant populations have had to develop novel ways of providing health care to this group.
“Rogelio,” I call out.
In the waiting room, among the sleeping, a young man stands up, wearing jeans and big, black boots caked with mud, a cap that says houston—no sports team, just houston—and a rosary around his neck. Just above the rosary, dangling out of his right jugular, is a cigar-shaped wad of cotton encasing a dialysis catheter, what doctors call a Permacath. As he enters the exam room, I can see that the gauze fibrils are coming loose and that his skin has turned a dollar-bill hue. Wrapped within the gauze—which extends about the width of two thumbs from his neck—is a large-bore IV with two syringe tips, one colored red, the other blue. This plastic tubing continues on (though sometimes it is dislodged) inside the young man’s body, down his jugular and the entire length of the superior vena cava until it reaches a junction with the heart. Sutures have been sewn below the jaw...