A Very Basic Failure

Everyone has heard at least one "health care nightmare" story, like the death of 17-year-old Nataline Sarkysian [1] hours after her insurance company approved coverage a liver transplant after repeated denials. Before that, it was the death of Diamonte Driver [2], for want of an $80 dental procedure. These stories naturally provoke outrage, but what happened to an anonymous 68-year-old man last year is categorized as weird news [3], even though it's as much about our failed health care system as the familiar "nightmare" stories.

The abstract [4] of the article published in Journal of Emergency Medicine, in December 2007, is about as dry as you might expect a medical journal to be.

A 68-year-old man presented to the Emergency Department with a severe metabolic alkalosis after ingesting large quantities of baking soda to treat his dyspepsia. His underlying pulmonary disease and a progressively worsening mental status necessitated intubation for respiratory failure. Laboratory studies revealed a hyponatremic, hypochloremic, hypokalemic metabolic alkalosis. The patient was successfully treated after cessation of the oral bicarbonate, initiation of intravenous hydration, and correction of electrolyte abnormalities.

Aaron Rowe of Wired Science [5] gave a more colorful summary of the story. Basically, a 68-year-old man slips, falls, and ends up in the emergency room. Upon arrival, he's disheveled, incoherent, and acting strangely. Tests reveal that, while he doesn't have a head injury, the pH of his blood and urine were extremely high. As Rowe puts it, "his body fluids were way too basic."

The man becomes agitated, and emergency room staff give him tranquilizers, but ended up having to intubate him when the medication suppressed his breathing.Their patient stabilized, the medical staff finally learns why he ended up in such bad shape. See if you can spot the reason.

Once their patient was stable, the doctors questioned his niece. She had found several empty boxes of baking soda at his home and explained that her uncle, who lacked health insurance, had been using it to cope with severe indigestion.

With an understanding of what had went wrong, the doctors gave the patient fluids and potassium and potassium, which invigorated his kidneys. Slowly, the problem fixed itself.

You might think that what went wrong was the man's use of baking soda to treat what he thought was indigestion. (According to Rowe, it was stomach pain caused by an ulcer.) You might think that, but you'd be wrong. What went wrong was that this 68-year-old man did not have health insurance, and faced the the same singular option as 47 million Americans without health insurance [6]: making do.

When I read the story, I thought "there but for employer-provided health care go I." I've been in the same position as this guy, including the baking soda remedy. My story didn't end in the emergency room, after suffering for who knows how long with an undiagnosed and untreated condition.

I have Gastro Esophageal Reflux Disease [7] (GERD). Basically, it means that the bottom of my esophagus doesn't close properly, allowing food and stomach acid to move upward into the esophagus. My father very likely had it [8], too. He passed away in April 2006 [9] due to an esophageal cancer [10] that was very likely related to having untreated GERD for decades.

Like the man in the story, I used baking soda as a remedy almost every night—and sometimes several times a night—for what I thought was indigestion. The remedy [11] is simple—half a teaspoon of baking soda dissolved in half a cup of water—and it probably works for simple indigestion. But in my case it didn't. Neither did various over-the-counter medicines I tried, because I didn't have simple indigestion. The pain got worse, and I ended up vomiting almost every night.

But I had health insurance through my job (and a spouse who nagged me until I made a doctor's appointment). After an upper g.i. endoscopy [12] and, a bit later, a Barium swallow x-ray [13]—paid for by my insurance— my doctor confirmed that I had GERD, and sent me home with a prescription that—minus my minimal co-pay—my health insurance also paid for.

Without health insurance, I could very well have ended up in the same position as the man in the Journal of Emergency Medicine article, or even at risk for the same cancer that killed my father. But I didn't, because I had health insurance that gave me access to medical care, which resulted in a diagnosis, and treatment that has prevented me from ending up in an emergency room.

Last week, a post by Tula Connell [14] reminded me of President Bush's advice for uninsured American's like this man:

I mean, people have access to health care in America. After all, you just go to an emergency room.

But emergency rooms don't do the kind of early detection and diagnosis I got and that this man needed. They only take critical cases, because that's emergency medicine. (And, if the death of Edith Isabel Rodriguez [15]—after 45 minutes of writhing on an emergency room floor, suffering from a perforated bowel—some critical cases are passed over.)

Emergency rooms don't treat chronic or ongoing conditions. They stabilize you and send you on your way, or to a department that can offer all of the above. Emergency care is much more expensive than preventative care, though insurance will pay for former. If you have it. If not you'll leave the emergency room which a sizable bill. After six days in the hospital, the patient in the story above probably left the hospital with a bill he could no more afford than the health insurance that might have helped him avoid the emergency room and the emergency room bill in the first place.

Emergency rooms may also send you off with a prescription, as with the patient in the story above, but if you can't afford insurance, you probably can't afford the full price of the medicine. Given that, and the reality of a chronic condition that will inevitably flare up again without treatment, the 68-year-old man in the National Journal of Emergency Medicine article will very likely return turn to the ineffective home remedy. He'll probably return to the emergency room again. If he's lucky.

This man's story might qualify as "news of the weird," but it's really another story about the basic failure of the health care system.

Crossposted from The Republic of T. [16]