Part IV: Case Study Ellen— Another Trip to the ER

I returned to DC on Monday and my intention was to visit Ellen at the Rehab Center and see how she was doing.  The plan was that she would be there for a while to regain her mobility and then go home.  As I was driving I decided to call Ellen's daughter to see how things were going.  

She let me know that the Rehab Center wanted to call 911 and have an ambulance take  Ellen to Suburban Hospital.  Ellen's white blood cell count was high and they felt she needed to be taken there even though her primary doctor was affiliated with Georgetown University Hospital (GUH).  We were told that the Montgomery County ambulance would not take her to GUH which is located in Washington, D.C.  The only way Ellen could get to GUH was by hiring a private ambulance. And so we did.

So once again Ellen, her daughter, and I were on our way back to the ER.  This time I  let the Georgetown staff know we were coming ahead of time.  We were glad that Ellen was put in the same area designated as Fast Track B. We chuckled about what "Fast Track" means.  

This time Ellen had a wonderful nurse (Jason) who did all he could to make her comfortable.  The 4th year resident (Bobby) had a good disposition and was very patient with her. Ellen had blood drawn, ultrasound of a swollen leg, chest x-ray, and answered many questions. The physician on duty told us that her white blood cell count should not have been alarming as that may have occurred because of some of the medicines she was taking.

In the end they released her to go back to the Rehab Center.  There was nothing wrong with her or perhaps more accurately there was nothing found that could be fixed. Consequently, at 2:20am on Tuesday Ellen was transported back to the Rehab Center by the regular ambulance service.  On Thursday at 1:45pm Ellen died.

Part II: Case Study Ellen— Water, nutrition, and the right mattress

My 83 year old friend Ellen was admitted to the hospital because she was dehydrated and very weak.  While in the ER I was told that she also had the beginnings of a bedsore. And while I was glad that she was admitted there were some observations that raised concerns:

• Just like in the ER health care professionals end up spending more time in front of a screen than in direct patient care.
• On Day One Ellen was given a large container of ice water with a straw so she could drink water.  The person who brought it did not realize she was too weak to either lift the container or suck from the straw.  I asked that she be given water in a cup and it was written on the board.  When I came back on Day 2 there was a pitcher of warm water that she could not lift and the glass. I got her ice water and filled her cup.  During the time I was there she drank 8 ozs of water.  I told the nurse how much she had to drink but I don't think anyone was really monitoring her intake even though the reason she was admitted was dehydration.
• Ellen had asked for tissues and while I was gone they left her two boxes---unopened.  I had to open one for her the next day when I returned.
• Since Ellen is very weak she is not able to eat very much.  I asked if they had Ensure and they said yes. I asked that she be given chocolate Ensure because she will usually drink it.  She was given vanilla.  When I inquired I was told, "... they send what they have."  It was not till Day four that she finally got the Chocolate Ensure.
• Although the beginning of a bedsore was pointed out to me while in the ER, Ellen was not given the special mattress to decrease the likelihood of the bedsore getting worse. 
• The care team is supposed to write their name but the only ones who did so were the nurses.

Better than most, I understand the stressors in health care, but some small low cost actions ( water, edible food, the right mattress) would definitely make the patient experience one conducive to getting better.

Part I: Case Study Ellen— If It is Weds. Night I Am in the ER

Over the past four weeks I have spent three Weds evenings in the ER with a friend (two times with Ellen and one time with David). One time at Sibley Memorial Hospital (part of Johns Hopkins Medicine) and twice at MedStar Georgetown University Hospital.  I wish that I could say that one experience was better than the other but the reality is that neither ER was what I had hoped.  They both shared some concerning similarities:

• Both had staff who spent more time in front of a screen than with patients.
• It was hard to know who could answer questions.
• Getting admitted into a room required waiting, and waiting, and waiting.
• There was no privacy...everyone hears everything...so all the HIPPA stuff seems irrelevant.
• Cleanliness did not seem a priority.
• Getting a glass of water was challenging.
• The transition from the ER to a hospital room took too long.

The major takeaway is that people go to the ER when they do not know what to do or when there are no other systems to take care of them.  That certainly was the case for the patients who's assessment I could hear through the curtain that separated us: the person who had a problem with alcoholism and was recurring visitor to the ER, the person who would go to a psychiatric unit because she said she had no place to get her  medication, as well as the person who was in a nursing home and prone to falling.  

Everyone waited patiently because it was clear that the ER needed help. 

Uninsured ER Overcrowding . . . It’s a Myth

Perhaps the most frequent scapegoat for the crisis in our health system is the uninsured.  For decades the litany of attacks on the uninsured has been they are overcrowding emergency rooms and using scarce resources because they do not go in for regular ongoing care.  But buried in today’s newspapers, ensuring that it will get scant attention, was reporting on new research released by the Journal of the American Association (JAMA) that turns conventional wisdom on its head.

The study found that the uninsured are less likely than those with insurance to use emergency rooms.  In fact, while 17% of persons in our country are uninsured, they only represent between 10% to 15% of emergency room visits.

When you talk to people who are uninsured they tell you that they do everything they can to take care of themselves; after all not everyone gets sick leave.  They also avoid emergency rooms because they are already living at the edge and are concerned that the costs they incur from an emergency room visit will push them off the precipice to which they are clinging.

According to the JAMA study, insured patients represent the majority of increased use of emergency rooms over the past decade.   So while providing health insurance to those who cannot afford it is critical, it does not go far enough to make our health system what we know it should be.  Access is about more than having coverage.