owclaw’s blog

The Uninsured Patient

Shiban Ganju

My pager beeped while I was standing in line in Starbucks. I checked the message it was the telephone number of the ICU. I ordered my coffee and stepped aside to call. The nurse informed me, that I was asked to consult on a 33-year-old patient who had been admitted the night before. He had uncontrolled diabetes and had vomited blood.

What is the hemoglobin?

Thirteen.

Not bad. Is he on any anticoagulants?

No.

Any history of alcohol?

No.

Any aspirin or ibuprofen?

No.

I grabbed my grande and rushed to the hospital. In my mind, I rearranged my schedule for the day and decided to start with this patient in the ICU. I figured it will take me a few minutes, but I was not prepared for what I saw.

An oversize man lay sprawled on the bed from one side-rail to the other. He looked bigger than his stated weight of 367 Lbs. His gullet rattled behind the oxygen mask, as it croaked with each breath; beads of sweat glistened on his balding scalp; his huge flaccid limbs lay motionless. His pale face announced impending death. I glanced at the monitor: his heart galloped at 120 beats and his blood oxygen level touched a critically low number.

“Get me a blood gas and call respiratory.”

I sensed the danger. In a few minutes, the blood gas result showed that his oxygen level and pH (blood acid level) were incompatible with life. The respiratory team showed up and we inserted a tube into his trachea and connected him to a ventilator.

We injected sodium bicarbonate to neutralize excess acid in the blood and rushed in more intravenous fluids. The numbers on the monitor showed improvement. We sighed relief.

Now we had a small hiatus to recapitulate. JD was a truck driver on a long haul and had become nauseous and dizzy driving on the highway, six hundred miles away from his home. On seeing a hospital sign, he had got off the highway and staggered into the emergency room. JD’s life was succumbing to diabetic keto-acidosis, also called diabetic coma. An untreated bronchitis had progressed to pneumonia, which had triggered this disaster.

He was now temporarily stable for me to inspect his stomach for bleeding. I slipped a fiber-optic endoscope into his esophagus and advanced it into his stomach and duodenum. Flecks of blackish curdled blood covered the stomach lining. I searched every corner but could not find any fresh bleeding, which was good news, but it also made me uncomfortable because I did not know why he had bled. I had expected to see small ulcers, but he had none. I stopped the procedure and pulled out the ensdoscope.

I called the primary physician and updated her about JD and advised her to request pulmonary, endocrine and infectious disease specialists to see this patient. We needed more help.

Before leaving, I enquired if JD had is family around.

I walked up to the waiting room. Two ladies, with fear on their faces, approached me and introduced themselves as the mother and wife. I explained to them in simple language about his serious condition. This was the time to know his story.

How long did he have diabetes?

Two years.

What medicines was he on?

He was trying to control it by diet.

Is that what his family doctor had recommended?

No, he had prescribed some pills but he never followed up.

Why not?

He had no insurance – we have no insurance.

JD was a hard working honest man who was teetering at the edge of life because he could not afford health care insurance. About eighty percent of all uninsured people belong to such working families. Even middle class families find health insurance beyond their reach; about 40 percent of uninsured have a household income of $50,00 or more.

His employer had dropped health insurance because he could not afford exorbitant insurance premiums.

I looked at my watch: we had been there for two hours, which meant I would spend rest of the day trying to catch up. The accusative looks of the patients waiting in my office haunted me especially. I decided to go to my outpatient office first and postpone my hospital rounds for the evening and I would just apologize for being tardy.

Close to the end of my office hours, I received a call from JD’s nurse. JD had again vomited blood and he had produced no urine since the morning; his hemoglobin had dropped to 8 grams suggesting serious blood loss and his kidneys were failing. I asked the nurse to transfuse two units of blood, get a kidney specialist to see JD and get ready for a repeat endoscopy. I hurried my last patients out of the office and rushed back to the ICU.

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