(Another American health care fable)
The ambulance siren wailed loudly and the madly rushing vehicle careered through the narrow streets. Time was of the essence, as is always the case when a life is in danger.
The occupant, the center of attention of the concerned paramedics, grasped the side-bars of the stretcher. The violent gyrations of the speeding ambulance weren’t helping the pain in his chest or the rapid pounding of his heart.
Just a few minutes before, he, Joseph Toad, a 60ish wealth manager, aiming for retirement in a couple of years, had been at a Starbucks near his office downtown, drinking coffee and waiting to meet a client. Little did he know that events out of his control were about to coalesce into a “perfect storm” of platelet adhesiveness, inflammation, and hypercoagulability. It was Monday. It was morning. He was male. He was 60ish. He had a Type A personality. His father had died when 60ish of a sudden heart attack. He had a big, stressful appointment with an important client coming up. All risk factors for coronary thrombosis. And so it happened.
The ambulance arrived soon after the Starbucks baristas made the 911 call. Electrodes were applied, IVs were started, nitroglycerin was given. The pain in his chest was still sitting there, like the proverbial elephant. It was imperative that he be brought to a hospital in short order.
Despite his chest discomfort, the seemingly reckless ambulance ride was taking even more of a toll on his nerves. “Slow down!” he suddenly shouted.
One of the uniformed paramedics turned to him. “Don’t worry,” he said, glancing up at the rapidly beeping cardiac monitor. The hint of fear in the tone of his voice did little to allay Mr. Toad’s concerns. “We should be at the hospital soon,” he added, trying to be reassuring.
“I’d like to get there in one piece,” Mr. Toad said in a mildly reproachful, joking manner. To take his mind off both the wild ride and his chest pain, he sought to continue the conversation with the paramedic. “Why is it taking so long to get there? We surely must have passed some hospitals by now.”
“Well…no,” replied the paramedic, whose name Mr. Toad could not make out on his name tag. “I think if you’ve lived in this town for any length of time you’d know that all four hospitals are located in the East End of town, within a quarter mile of each other.”
“I hadn’t given it much thought,” stated Mr. Toad. He himself lived in the East End. It was the wealthy part of town. Of the competing hospital systems in town, all had wanted to locate their hospitals closest to those clients who had the best insurance, and the greatest ability to co-pay. Being a wealth manager by profession, this strategy certainly made sense from the economic, if not humanitarian point of view. Mr. Toad briefly cursed the bad luck that had led him to have his heart attack while downtown and not at home, close to a hospital.
“Wait!” he exclaimed, struck by an idea. “What about the University Hospital? It’s downtown. It’s closer.”
Both the paramedics next to him snickered a little at this suggestion. The one who hadn’t spoken yet said, “I’m sure you wouldn’t want to go there. You are nicely dressed and trust me you wouldn’t fit in with the clientele at the University Hospital. Patients there are over 90% Medicaid, Medicare, or indigent. You wouldn’t fit in at all.”
“Besides,” the other paramedic chimed in, “our ambulance service has a contract with several of the Big Players in Healthcare in this town. We’re better off going to one of their hospitals.”
“Better for whom? Me or you? I’m the one with the heart attack!” shouted Mr. Toad. This wasn’t good for his blood pressure, which was rising.
“Whoa, sir. Calm down. My partner here is going to give you a little shot of morphine. That should help relax you and help you with that pain. Your condition looks pretty stable at this point. You will be better off taking a little longer ride, since the East End hospitals have state-of-the art heart cath labs, state-of-the-art equipment and state-of-the-art doctors. Door-to-balloon times are as short as anyplace in the country. At the University Hospital you would be treated by docs just out of medical school, or still in medical school. They probably wouldn’t take you to the cath lab at all. Maybe they’d just give you a thrombolytic, you know, a clot-buster. But that usually doesn’t work. And then you’d be in some ward with four other people, homeless types. And no TV.” While he was talking the other paramedic prepared the injection and then gave the morphine through the IV.
Mr. Toad calmed down somewhat, though whether it was from the medication or the paramedic’s attempts at reassurance he couldn’t be sure. It still bothered him that by going to a more distant hospital there might be more of a risk of his dying during the ambulance ride. But he supposed they had all the equipment to revive him here in the ambulance if needed. Being a wealthy man he did admit to himself that he would prefer a private room to being in an open ward, and he knew that in the long run he would get better care if he got it in one of the fancy East End hospitals.
For a while he was silent, lost in his thoughts. The pain was not gone, but was down to a 3 out of 10, to use the pain scale the paramedics had taught him. The ambulance sped onward…
One of the paramedics was talking into a microphone. “What’s going on?” Mr. Toad asked.
“We’re radioing ahead to the EDs, you know, the emergency departments,” the other answered. “Sometimes one hospital cath lab is occupied, or there is a bed crunch and the hospital is on divert. Since we have a choice of four different hospitals, and they are all within a block of each other, we have a lot of options.”
“And I suppose you are letting them know my condition.”
“Well, they know you’re having a STEMI — that’s a serious heart attack — and, believe me, they know what they have to do.”
Again Mr. Toad felt reassured. They had to be close to the hospital now, and relief from his pain was probably not far away. Now that it was almost over, the long ambulance ride probably had been the right thing to do after all.
“Problem?” one of the paramedics asked the one at the radio.
“Yeah. Sts. Elizabeth and Bartholomew has closed off one of their cardiac units. They’re upgrading their TVs to 60 inch screens. They’re full and begging us not to stop there.”
“Too bad, probably shortest door-to-balloon time there, but check with Latter-Day-Saints, Haussmann Plaza, and HumanCare.”
Mr. Toad wasn’t really medically savvy, but realized the door-to-balloon time had something to do with how quickly his heart attack could be relieved. He knew that somehow the doctors used a catheter to put a balloon in the blocked artery and blew up the balloon to open the blockage. They then would place a metal stent to keep it open. He had watched something about this on the Discovery Channel, never realizing the information would apply to him.
There was no cause for alarm, but he found the morphine was wearing off, and his pain level was now a five.
“Damn!” the radio-operating paramedic exclaimed. “HumanCare is on divert too. Apparently they’ve been overloaded because of the shut down unit at Saints E and B.” The other paramedic also cursed under his breath, and quickly moved up to the little window at the front of the cab, where he communicated this information to the driver. In response, the vehicle braked suddenly and changed course.
“Heading around the block. Still have a couple more choices,” he informed his patient.
There wasn’t enough time to radio ahead, as they had already arrived at the Haussmann Plaza Hospital ED. The doors at the back of the cab flew open and the paramedics prepared to slide Mr. Toad’s stretcher outside. Looking out the open doors, Mr. Toad could not help but be impressed by the view — despite his mounting chest discomfort. Was it a 7? An 8? He began to wonder what difference it made. Still the view grabbed him and distracted him from his pain somewhat.
Haussmann’s was a glittering glass spire, the newest and most modern hospital in town. He remembered reading about it in the paper. It had the works. All private rooms of course. Amazing views out the huge windows. A huge ornate chandelier of Venetian glass adorned the spacious lobby. World famous chefs manned the wonderful kitchen where gourmet meals were the routine. Huge wall-mounted flat screen TV sets, with hundreds of channels, first run movies, and interactive video games. Free wifi Internet service. And, in addition to state-of-the-art traditional medicine, Haussmann’s also provided access to popular forms of alternative, or, as they termed it, complementary medicine. This included non-traditional remedies such as St. John’s Wort, Ginseng, ground up shark fins, and many herbs and spices, as well as treatments using acupuncture, chiropractic, homeopathy, naturopathy, and basically any -opathy the patients wanted. Holistic healing was the name of the game at Haussmann’s. Mr. Toad, thinking of the amenities, was happy he had ended up here.
“Whoa! Whoa, whoa, whoa, whoa!” someone shouted.
“What?” shouted back one of the paramedics.
“Didn’t you guys call ahead? Didn’t you hear?”
“Man, the Food Network’s here today. They’re filming an episode of Cupcake Wars right here in the hospital kitchen. They’re got the hospital Chief Chef on as one of the three judges!”
“So the place is shut down until tonight. In other words, we’re on divert big time right now. In fact, one of the show’s producers is taking some outside shots and wants your ambulance out of the picture, pronto.”
“Listen, we’re got an acute STEMI in here and he’s not thriving, if you know what I mean!” shouted the paramedic.
“Listen yourself. There’s a bunch of other hospitals within walking distance. Now shove off. Bobby Flay’s around here somewhere and he’s not going to be happy to see you.”
In a matter of seconds the paramedics had jumped back into the cab and the doors were shut. The ambulance took off with a screech of its tires.
“Hotchelds,” the two paramedics said, almost simulataneously.
“What?” muttered Joseph Toad. He was feeling a little dizzy, like maybe he was slipping into shock. He didn’t know what was going on, because he wasn’t a doctor, but he didn’t feel good.
“Hospital of the Church of the Latter Day Saints,” one them said. “It better not be on divert.”
“You going to call ahead?” one asked the other.
“Nah, what difference would it make. We don’t have any other options. And here we are already anyway.”
Once again the doors flew open and this time Mr. Toad was out of the ambulance before anyone could object. In moments he was inside the Emergency Department. The two paramedics were rapidly talking to a triage nurse. The nurse took down a few notes and then came over to Mr. Toad.
“Hello I’m Nurse Kelly, the triage nurse. I hope you’re having a good day. Tell me what hurts.”
“It’s my chest, nurse. It’s been hurting for more than an hour now. It’s taken a long time to get here because the other hospitals were on divert, and I’m worried my door-to-balloon time is going to be too long.”
The nurse smiled. “Oh, I wouldn’t worry about that. The door-to-balloon time only started when you went through our door, which just happened. It’s supposed to be under 90 minutes, so we still have plenty of time.” She brought up her clipboard and a pen. “There is some paperwork we need to complete, some documents and consents you need to read and sign, and we need to make you fully aware of this hospital’s compliance with the HIPAA law.”
“Please, nurse, get me a doctor right away,” Mr. Toad begged. “I think I am dying.”
The nurse looked serious. “Of course that is very serious. I always get worried when a patient says they think they are dying, because, nine times out of ten, they do. It’s like some kind of self-fulfilling prophecy. Look, we’ll skip the unimportant paperwork until later. I just need one crucial bit of information from you.”
Mr. Toad did not look good, even to a lay person. His skin was gray and clammy. His heart rate which had been fast was suddenly slowing down markedly. His pain felt like something trying to burst out of his chest, like the monster in the movie Alien. Weakly he responded to the nurse. “Anything, anything you want. But quickly please.”
“Of course, sir. Do you have your insurance card with you?”
Mr. Toad groaned, but somehow was not surprised by the question. He managed to pull his wallet out and get the card out. He handed it to the nurse.
“Oh,” she said. “Oh, oh, oh. This isn’t looking good.”
Mr. Toad thought she was referring to his condition, but she wasn’t.
“I’m sorry sir. You should have informed the ambulance personnel what insurance you have. We pulled our contract with National Happiness Insurance a month ago. They wouldn’t come to our terms in the contract negotiations. It’s a tragedy really. I had a lot of very nice patients with that insurance.”
Mr. Toad was speechless.
“But, good news. There are 3 other hospitals within a quarter mile of here that take National Happiness. According to federal law, in this situation our duty in the Emergency Department is to stabilize the patient so that he or she can be transferred to a facility that can provide longer term care.” The triage nurse took a quick gander at Mr. Toad, who at this point was beginning to lose consciousness.
“Good Lord, we don’t want an arrest on our hands.” She waved to the paramedics who were still there, having a cup of the awful ED coffee as was their usual practice after dropping off a patient.
“You there. We don’t take this man’s insurance. He can’t stay here.”
The two paramedics rushed over, grabbed the stretcher, and in a moment Mr. Toad was back in the ambulance. The third paramedic, who was the ambulance driver, started the engine and turned the flashing lights and siren back on. One of the other paramedics moved up to the little window that connected the cab of the ambulance with the driver’s compartment.
“University?” asked the driver.