Playing Roulette with a Life

By Sarah Smith, MD

Another backboarded body rolls in. I slip from my perch at the computer and greet the emergency medical technician.

“Seizure. Lasted a few minutes, done by the time we got there. Fell and cut his face.  Vitals stable. Sugar fine. Oriented but postictal.  Didn’t take his meds.”

Approximately my age, the backboarded man’s chin bears a ribbon of red laces.

“Dammit,” he says. A glance at the cardiorespiratory monitor shows me suitable hemodynamics, and I begin a cursory neurologic exam.

“Hello, sir, I am Dr. Smith, the resident working in the ER today.  It seems you have had a seizure, has this happened before?”

“Yes,” he groans. “I didn’t take my meds.  How could I let this happen?”

He raises his hands to his face, pulling them away to reveal blood from the laceration sustained on his chin.

“I am going to lose my job,” he says. “I have to work!”

His eyes are earnest and desperate.  I think of my father.

“When were you diagnosed with epilepsy?” I ask him.  A primary seizure disorder in early adolescence.  I learn further that he is uninsured and cannot afford his medications.

When he takes his medications his illness is controlled.  He does not seize in his employer’s store room. His startled co-workers do not call 911. He is not delivered by ambulance to an emergency department where evaluation and treatment incurs a bill several magnitudes greater than the cost of his preventive medication.

He understands that he is playing a game of Russian Roulette with his life every day he doesn’t take his medications, but the money isn’t there.

I irrigate and drape the wound on his chin and lean over him, suture in hand, to repair the injury.  I reflect on several months prior, when my mother called me to tell me my father was in the intensive care unit back home, hundreds of miles away.

“He wouldn’t stop seizing.”

I was sick to my stomach as I arranged an emergent flight home.  I arrived at the hospital after the excruciatingly long trip and rushed to my father’s room to find him intubated and receiving a propofol infusion.

Two days later he was delirious, begging my younger brother and I to remove the restraints holding him to the bed.

Three days later he was ambulating slowly down the hall.  In a week he was in a skilled nursing facility, working with therapists to learn compensatory mechanisms for the memory deficits incurred.

Then the bills arrived.  My parents, with insurance that many would consider excellent, were still charged several thousands of dollars.  The focus on my father’s recovery was undermined by anxiety.  The retirement planning that had been underway was deferred — they both would need to work for a while longer.

I tied the last suture on the young patient in front of me and removed the drape.  He was suitable for discharge.  I arranged his prescriptions and set up an appointment in my clinic for follow-up.

“I will be there, “he said, absentmindedly tucking the paper into his pocket.

I surprised myself with the cynicism I felt in response.  I am far too young in my training to have my idealism threatened, but the system — as it is — fosters skepticism.

I want my patients to be able to afford the evaluations and treatments that will prevent undue physical, emotional, and financial morbidity.  I am about to embark on my career in primary care and will work earnestly to provide preventive and affordable care — work I hope our healthcare infrastructure will allow.

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Sarah Smith  will be completing a residency in Internal Medicine and Pediatrics at Tulane University this June and have will join the Department of Internal Medicine and Pediatrics of the Nebraska Medical Center this summer.  She was a contestant in the 2013 Costs of Care Essay Contest.