Playing by the rules

In the emergency room yesterday discussing contraception with a 17 year old who had just had a miscarriage:

Doctor: "Were you and your boyfriend using anything for contraception?"

Patient: "We're Catholic and our church doesn't allow us to use contraception."

Doctor: "Oh, you two are married?"

Patient: "Well, no! I am only 17!"

Doctor: "So, when did your church start letting you have sex before marriage?"

Silence.

My crystal ball

Well, here I am. Back for more work at the big medical center. When I was last here, 2 days ago, I admitted and operated on a patient who came in through the emergency room. Both the emergency room physician and the radiologist who preformed the sonogram felt she had a twisted ovary. I agreed. Her symptoms, the signs on her physical exam, and the sonogram were compatible with this diagnosis.

Problem is this was not the problem. The problem was a large fibroid which had outgrown the blood supply. Painful yes, but not as much of a medical emergency as a twisted ovary. Also the solution to the problem of the necrosing fibroid had to be solved with a hysterectomy due to the location. This resulted in a longer and more difficult procedure than the one I would have used for an ovarian torsion.

The patient is past the age of normal child bearing. She even had a tubal ligation with her last child some fifteen years ago. The problem is she has a government funded health insurance which requires a thirty day consent for hysterectomy. Even with this knowledge, to cover all the possibilities, I discussed hysterectomy as an emergency procedure and ask her to sign a consent form for this in the emergency room.

Carefully reviewing my documentation, I worry this case will be refused payment by the third party payers. Even though I know I preformed the correct procedure for this patient, I am bothered because this will be a mark against me with the hospital administration. The hospital will not be paid for any of the care of this patient. It is the same with tubal ligation in pregnant patients. Even if the woman has had twelve children at home, the consent form must be signed thirty days in advance.

So, I find I not only need a crystal ball to aid in diagnosis but a magic wand. The magic wand would come in handy for situations such as the above. I could make the treatment fit the payers criteria rather than just doing what the patient needs.

Falling through the cracks

In private practice I was always worried a patient would, as we say, "fall through the cracks." The cracks are spaces in the health care system where patients, especially those with few resources, get lost to follow up and go months or years without care. They finally reappear in an emergency room in crisis.

In my new position, most of my patients have fallen through the cracks. Examples I have come in contact with just today are:

O who had a fibroid uterus so large it was obstruction her intestinal tract. While she has government supplied health insurance due to her mental disability, she fell through the cracks because she is schizophrenic. The county system gives her medication for her schizophrenia. She can manage with her son's help to get to the Mental Health and Mental Retardation office for her medication checks but she tells me the paper work for the primary care doctor is too difficult for her to fill out.

Or there is D. She was going to a Medicaid clinic run by a doctor who doesn't have privileges at any local hospital. When D's bag of waters broke prematurely, she called her doctor but no one ever called her back. That was three days before she came into the emergency room with an infection from the premature rupture of membranes. And just so those of you out there who are thinking, "We don't understand why she didn't go to the hospital right away!" know, I thought of that too. When I asked her, she explained she has had two babies and two miscarriages at the county hospital. I don't think she was treated very well on any of those hospital visits.

Now there is B. I am waiting on the OR to call me. She has an ectopic pregnancy. She had a positive pregnancy test two weeks ago. She has a job and a three year old son. She was trying to figure out whether she qualified for Medicaid since her employer doesn't provide health insurance. I am hopefully we will be able to do an minimally invasive procedure and get her back to work in a week or two since she and the three year old depend on this job, which she is afraid she will lose. In this economy you can understand.

The cracks are scary. Most of my friends cannot imagine they would every fall through them. I believe the cracks are a hazard for those of us who make a good living, as well as those who live on the edge of a crack economically. We are all just one serious illness, just one disability away from a crack. A crack which all but the richest could fall through.