This is Part 2, for Part 1, click here.
The Last Chance Democracy Café
Episode 46.2: Unimaginable Goodbyes
by Steven C. Day
Stuck in the family quiet room, Zach and I had no idea what was happening with Horace. Despite the nursing director’s assurance that someone would be in to update us, we hadn’t seen a soul. We didn’t know if he was dead or alive, and if alive, what his condition was.
The uncertainty was gut-wrenching — and more than a little infuriating.
“Where the hell are they?! Why doesn’t someone tell us what’s going on?!”
Speaking as a lawyer who used to defend malpractice cases, I can tell you that this is a very common complaint by loved ones: “No one told us what was happening.” Sometimes this is due, I think, to unreasonable expectations by the family, and sometimes it’s due to insufficient sensitivity by the health care providers; either way, it causes a lot of anguish.
To be fair, most hospitals have been working in recent years to improve the level of communication with family and friends during emergency situations, trying to reduce the ill will, not to mention increased litigation risk, generated when loved ones feel abandoned.
But when all hell is breaking loose and there just aren’t enough hands, as was true this evening, sometimes something has to give.
Zach and I were that something.
Finally, I decided to investigate. The feeling of dread, as I inched open the door into the main emergency room treatment area, was like nothing I’d ever felt before. Zach’s words kept running through my mind: “I think he’s dead, Steve. I really think he’s dead.”
And based upon what I knew at the time, I had little cause to doubt Zach’s instincts. I knew, for example, that according to the American Heart Association, a full 95 percent of cardiac arrest patients die before ever reaching the hospital. And although I would later learn that the survival statistics are much better for those patients, like Horace, who suffer their arrest in the hospital, especially those, again like Horace, who are on cardiac monitors, at that moment, as I set out in search for answers to my friend’s fate, hope seemed as elusive as Don Quixote’s lady Dulcinea.
But as I stepped through the door there was nothing — nothing. No gurney; no code blue in process; no Horace.
Surely they wouldn’t have taken his body away without talking to us, I thought to myself.
I stood there, all alone on the empty stretch of hallway that had so recently doubled as my friend’s “hospital room,” for what must have been a couple of minutes. I was apparently invisible, as a procession of doctors, nurses and orderlies dashed back and forth, oblivious, it seemed, to the fact that I was standing there with an unmistakable look of anguish on my face.
“Weren’t you with Horace?” the voice behind me asked.
“You were with the man here, who had the cardiac arrest . . . Horace, right?”
I turned around. It was the nurse with the nametag that read Janet L. R.N., who had helped care for Horace earlier.
“Is he . . . is he alive?” I asked.
“No one’s talked to you?” Nurse Janet L. sounded surprised.
“No, no one. Please tell me, is he alive?”
“I’ll try to get the doctor to speak to you . . .”
“So, he’s dead then.”
Nurse Janet L. hesitated. I think she didn’t want to talk out of school, but she also didn’t want to leave me with the wrong impression. “I really wish you’d wait to talk to the doctor, because I wasn’t there for all of it. But no, he didn’t die. In fact, they got him back into normal sinus rhythm fairly quickly . . . with just one shock, which is generally a good sign. I think I heard that he later regained consciousness and was even able to sign the release for the cath himself . . . But the doctor really needs to give you the . . .”
“So where is he now?”
“The doctor . . .”
“No, Horace. Where is Horace now?”
“I think he’s in the cath lab.”
“Through the ER door and down the main hallway to the right.”
And with that I grabbed Zach from the quiet room and rushed down to yet another waiting room, picking up along the way the growing throng of Horace’s friends, now including many members of his church.
Again, we waited for what seemed like forever, until, eventually, someone filled us in on the results of the catheterization: They were a mix of bad and good news; Horace had severe narrowing of his coronary arteries and needed immediate bypass surgery. On the other hand, the heart muscle itself still looked healthy, meaning he had a good chance for an excellent recovery.
We took turns staying with him until it was his time to go back for the surgery. The procedure itself, a triple bypass, lasted for a little over five hours, during which time the surgical team removed several healthy blood vessels from his leg, and then, stopping and restarting his heart along the way, used those vessels to bypass the clogged portions of his coronary arteries so as to create new pathways for blood to flow to the heart.
Then they gave us our friend back.
By the time the surgeon came out to advise us that all had gone well, nearly 50 people had gathered. We let out a cheer as loud as any I’ve heard at a football game.
When I think back to that night, I’m struck by how much Horace’s journey through the hospital was a microcosm for both what is so very good and also what is so very bad about our health care delivery system. On the one hand, today’s medical science has the technical capacity to do things that would have seemed like science fiction just a half a century ago, including the God-like sounding power to actually reengineer the blood supply to a dying human heart, to make it work again.
Yet, also clearly on display were the awful problems caused by our nation’s staggering, almost criminal, failure to provide basic health care services to all of its citizens.
I have to confess that in the days following Horace’s heart attack, I felt a lot of anger toward the staff and physicians working in the emergency room that evening: Anger over the way Zach and I were abandoned after Horace’s cardiac arrest; and more importantly, anger over their inability to get Horace back to the cath lab immediately, instead of having to wait until later, after he had already suffered his arrest.
But that anger is mostly gone now; which has a lot to do with my remembering something an expert witness — the director of an emergency department himself — once told me, back when I was a practicing lawyer.
He said, “Make no mistake. Doctors and nurses in emergency rooms sometimes screw up. And when they do, if patients get hurt, they should be held accountable like anyone else. But the truth is that in a very real sense these folks are heroes . . . they’re heroes. They work often under nearly impossible conditions, stretched to the breaking point, subjected to incredible stress, often forced to deal with angry and even abusive people. And yet they keep coming back, day after day, saving lives.”
We have a healthcare delivery system in this country that is seriously fucked-up, but it wasn’t the people who work in emergency rooms who fucked it up.
I mean, it’s staggering, really: 46 million Americans — 46 million — lack health insurance; and that number is growing every year. And while there are certainly other problems with how we provide medical care in this country, this one fact by itself has the potential to tear the entire system apart – something, in fact, it has already gotten a good start on.
Yet, despite overwhelming evidence that our national healthcare infrastructure is literally falling apart at the seams, Congress continues to lack the foresight (or is it guts?) to undertake any serious effort to improve the problem, let alone to tackle it in the comprehensive way needed.
Unfortunately, this unwillingness by our political leadership to deal with what is arguably the single most important domestic policy issue of our time, hasn’t prevented uninsured Americans from being so inconsiderate as to continue getting sick from time to time, and sometimes seriously so. And when that happens, somebody, somewhere and in some way has to provide them with medical care, unless, that is, we’re willing to simply let them die on the streets.
And the “somebodies” the Congress of the United States, in its infinite wisdom, selected to carry most of this extraordinary burden are the proprietors and employees of the emergency departments of community hospitals across the nation.
Enter the Emergency Medical Treatment and Active Labor Act (”EMTALA” ), first adopted in 1986; EMTALA is a perfectly appropriate and, indeed, morally compelling piece of legislation, as far as it goes — emphasis on “as far as it goes.” It was enacted to prohibit the reprehensible practice of so-called “patient dumping,” under which, some, though by no means all, private hospitals would dump uninsured patients, either by refusing to see them in the first place, or by transferring them in an unstable condition to public and charity hospitals, occasionally causing the death of a patient in the process.
Here’s how EMTALA works: As a matter of federal law, hospitals with emergency rooms are required to provide patients seeking emergency services with two things, regardless of ability to pay: First, an appropriate medical screening examination to determine whether the patient is, in fact, suffering from an emergency condition; and, second, if the patient is suffering from an emergency condition, then provide such treatment as is required to “stabilize” the patient.
So let’s see if we can add this all up:
1. We have tens of millions of Americans without health insurance, many of whom lack reliable access to routine healthcare because of inability to pay.
2. Federal law mandates that hospital emergency rooms provide at least limited care to such patients, regardless of ability to pay.
3. Emergency rooms, especially in poor urban areas, get flooded with uninsured patients.
Yeah, that was certainly unpredictable. We sure can’t blame Congress for not figuring that one out ahead of time. Only Carnac the Magnificent could have foreseen something like that.
Meanwhile, the financial pressures on community hospitals have been increasing from every angle. Reimbursements from governmental programs, like Medicaid, keep shrinking, as do the payments private insurance companies are willing to make; meanwhile, many parts of the country are being flooded with so-called “specialty hospitals” and minor surgery centers, which, because they don’t have emergency rooms, aren’t forced to take on indigent patients. This allows them to cherry pick patients who are insured or otherwise able to pay, further reducing community hospital revenues.
So to quote that great American scholar, Gomer Pyle, “Surprise, surprise, surprise!!” It turns out that between 1992 and 2003 the number of emergency room visits rose 26 percent, while the number of emergency departments open for business fell 14 percent, with more closing each year. While at the same time, more and more employers are dropping, or at least drastically reducing, health insurance benefits. And the incentive for businesses to make even more reductions in health coverage is likely only to increase, as American products, such as automobiles, become increasingly uncompetitive in pricing as a result of the huge American “health insurance surcharge,” which companies in other nations with saner, non-employment-based, systems for providing coverage, don’t face.
Someday, I suppose, our political leadership will have no choice but to seriously address the problem.
Just hope that you or a loved one doesn’t have to go to the emergency room before then.
It’s been a little over four weeks since that night. Horace is still recuperating at home, walking a little further every day. His daughter interrupted her long shot congressional campaign to take care of him, much to his chagrin.
“What are you doing here?” he started huffing about a week after the surgery. “You have a campaign to run.”
But his daughter had him on that one. “You were the one who always told me while I was growing up that family always comes first.”
“I always did talk too much,” was Horace’s only reply.
We expect him to be able to start coming back for Wednesday nights at The Last Chance Democracy Café in a few weeks, although probably only for an hour or two at first. One big change though is that he’ll have to start ordering from our low fat menu: His cardiologist has made it clear; no more Liberal Burgers.
Still, life goes on — thank God.
When not busy managing a mythical café, Steven C. Day lives with his family in Wichita, Kansas where he has practiced law for 25 years. Contact Steven at scday(AT)buzzflash.com.
© Copyright Steven C. Day. WGAw #974001