teri reynolds
DISPATCHES FROM
THE EMERGENCY ROOMI spent my early childhood in a trailer park in Texas so, until I became an emergency physician in Oakland, I thought I knew something about barriers to healthcare access, and maybe even something about poverty. The Emergency Department at the Oakland county hospital has around 75,000 visits a year—say, 200 a day. It has 43 beds; because of overcrowding, there are ‘extra’ patient beds in the hallways, which have ended up being designated as official patient-care areas: first came Hallway 1, then, a year later, Hallway 2, and now Hallway 3 as well. At night the ed usually has one supervising physician with a couple of housestaff—trainee doctors—a student or two, and around ten nurses; there is double supervising coverage from the late morning through to about 2 am, the hours of heaviest traffic.
County hospitals are where those with no insurance go. The elderly and disabled who qualify for Federal Medicare and Medicaid insurance may also go there, but they often take the insurance elsewhere. Those who have no insurance, no money and nowhere else to go, come to the county hospital. Our speciality is the initial management of everything. There are patients who bless me for my time, after they have waited 18 hours to see me for a five-minute prescription refill, and another who regularly greets me with, ‘Yo bitch, get me a sandwich.’ I did have one patient, born at the county hospital, who lied about his private insurance in order to return to what he called ‘my hospital’, but many more who feel they have hit bottom when they cannot afford to get care elsewhere.
Around 47 per cent of the patients are African-American, and 32 per cent Hispanic. We call the Mongolian and Eritrean telephone translator-lines on a regular basis. We also see the patients who are not entirely disenfranchised, but fall out of the system when they lose their jobs; most Americans have insurance linked to employment, either their own or a family member’s. It is not infrequent to see the primary reason for a visit to the hospital listed as ‘Lost Insurance’, ‘Lost Kaiser’ (the main private health maintenance organization in California), ‘Lost to Follow Up’ and once, just ‘Lost’, but we all knew what it meant. We see patients every week with decompensated chronic disease who say, ‘I was doing fine until I lost my job and couldn’t get my meds.’
Some of the visits are for true emergencies—there are 2,500 major trauma cases a year. These are usually shootings, stabbings, falls, assaults and automobile accidents; many, if not most, involve alcohol and drugs. In 2008 there were 124 homicides in Oakland alone, most of them due to gun violence; many victims have been involved in violence before. The Emergency Department gets a stream of teenage gunshot victims, cursing and yelling as they come in, swinging at medics and police with arms scored with gang tattoos; by the next day we see them emerge as the children they are, cowed by the presence of their mothers beside the recovery beds. We also see the bystanders, the teenagers who get shot while walking home from school, the elderly Chinese man hit by a stray bullet as he stepped outside to get the newspaper, the mother shot stepping in front of her son—who claimed not to know the shooters when interviewed by the police, but was overheard by the nurse the next day rallying his ‘boys’ for a revenge run. This kind of trauma has a way of turning victims into perpetrators. The first ‘death notification’ I did as an intern was to the mother of three boys. The older two had spent three months on the East Coast with relatives to let a ‘neighbourhood situation’ cool off. Less than 24 hours after their return to Oakland, they were shot while walking down the street together. The two older boys died. The 18-year-old had a collapsed lung, but survived. At his last trauma clinic follow-up, he was referred to social work for ‘clinical evidence of depression’, though at the time there was no outpatient social-work clinic available. ...........(more)
The complete piece is at:
http://www.newleftreview.org/?page=article&view=2819
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