Putting A Face To It

Today I received an order from one of our kidney doctors to remove a dialysis catheter from one of his patients.  "I don't know why Southwest left this line in when they discharged him a few days ago.  It needs to come out."  The line is one we consider temporary, and not safe to be left in outside of the hospital as it is only held in by a stitch, and if it comes out the patient could bleed to death if proper pressure is not applied.

Just another day in the world of health care...

 I had the patient come to our department after his dialysis treatment.  I noted that he was Mexican.  I asked if he spoke English and he said "Yes."  I asked what his plans were for dialysis if I removed his access.  He simply shrugged.  After a brief interview I realized that he was not sure if he still needed dialysis, and if he did, he was not sure how he was going to receive it. 

"Are you supposed to go home today?"

He said yes he was, but still didn't have an answer how he was supposed to get treatment.  I pulled up his chart on the computer and looked up the note from his doctor.

I was startled at what I found, but I could understand the reasoning behind it...

I had just never found myself in the position of explaining such things to a patient.  After a moment's thought, I read the following doctor's note aloud to the patient:

Patient is an undocumented worker from Mexico.  I instructed patient that he needs to return to Mexico where he can get health care, and continue treatment for his renal failure.  I also told patient that if he develops shortness of breath, he needs to return to the nearest hospital where he will be treated for his renal failure.

The patient became very reserved and stoic after I read the note aloud to him.  I asked if he understood what the doctor was saying.

He shrugged and avoided eye contact with me.  I wondered what he was thinking.  I wondered what he thought I was thinking.  Did he think I felt he didn't deserve health care because he does not have the proper paper work?  My reality is that even if he didn't have paper work, as a laborer, odds are he wouldn't have insurance.  Of course, our state Medicaid system would step in if he were a legal citizen.  Instead, this man has a serious, terminal if not treated illness, and no means to get it paid for. I quietly stood beside him and thought about his situation and the consequences.  I wondered if he was able to fully grasp what was going to happen with him, considering his not quite fluent English.  How do I explain what he is facing?  What do I say to a man that I know is doomed to death if he does not receive treatment?

Sometimes there are just no words to say.




After what felt like an eternity of silence, I asked him if he understood what it meant to lose function of his kidneys.  Again, he shrugged.

"Juan, once you've lost function of your kidneys, it usually means that it's permanent.  They are no longer able to clean out your blood of toxins and fluid.  Those toxins and fluids build up and you end up back in the hospital, unable to breathe.  The best thing you can do at this point is dialysis, which is what we've been doing.  Unfortunately, you don't have insurance, and you can't get insurance because you're not a legal citizen.  That is why Dr. K is suggesting you return to Mexico."

Of course he continued to look straight ahead, and barely acknowledge what I was saying.

"Has anyone talked to you about monitoring how much you drink and changes in what you eat?"  He didn't remember if they did.

I don't doubt that he has been instructed on both of those things.  I just don't think he really understood what he needed to do.  I tried to explain the importance of watching his fluid intake.  I talked about avoiding the salt shaker.  At first I thought he was not going to engage in the conversation.  He surprised me by asking how much he could safely drink in a day.  I told him that it varies from patient to patient, and he needed to ask Dr. K.  "However, a pretty basic measure is not over two liters."

Of course he had no clear idea of liters.  I told him to think of a big bottle of pop, and I got a foam cup and told him to not drink over nine of  those a day.  We discussed that he has to consider liquid from soups, jello, ice cream and even ice.  I gave the lecture on no soda and certainly  no alcohol.  He told me he doesn't drink "cerveza" and I told him I hoped that was so.

I removed his dialysis catheter with a heavy heart.  My mind was spinning with things he needed to know to have any hope of controlling this disease without dialysis.  And yet, I realize that all of those things are really just tiny bandages on a huge gaping wound.  After I removed his catheter I reminded him to leave the dressing on for at least one day.  I reminded him to ask about foods he should avoid, and what level he should keep his fluid intake at.  When I called report, his nurse was off the floor.  I asked the nurse taking report for him to please have her get a dietary consult so the patient can have a better idea of what foods would be safe to eat.

After leaving Juan's bedside, I went to my next patient.  Also of Mexican decent.  She speaks little to no English, and instead of removing, I was assisting in PLACING a permanent dialysis catheter.  She will go home and receive dialysis three times a week, four hours each day...And it will all be paid for by the tax payers because she is on the state Medicaid program.  You see, she is here legally.

Juan is not.

Same disease.  Same background.  Taxpayers will be picking up the tab for both patients.

I can't get  his face out of my mind.  He was a quiet man with unexpected green eyes.  He was slim and well groomed.  After digging through his chart as we chatted I discovered his kidney disease was probably caused by high blood pressure, which he had not realized he had until it was too late.  He still did not understand his high blood pressure when I talked to him.

When I'm outside the walls of the hospital it is easy to say that we have to stop giving health care to all of these illegals.  It's easy to complain about the drain on our budget that their children are, because they all get coverage.  However, when you are looking in the face of that person, and you know that they will surely die without proper care it is a big pill to swallow.

Of course, I realize Juan is still getting health care.  And, he's getting it for "free" as there is probably no way he will be able to pay, and no way for us to collect. 

I was physically ill as I spoke to him.  His condition will only get worse.  He will continue to go into a crisis of fluid overload.  This will cause him to either go to the hospital where he can get a temporary dialysis catheter placed like the one I removed today and receive a few treatments until he's "stable" and the doctor can discharge him and try not to let him weigh on too heavily on his already overburdened conscience.  (After all, any doctor that works for our hospital is not in it for the money.  We are known for giving away free health care.)  Or, Juan will literally drown in his own body fluid because his heart will be overloaded with fluid and literally give out from inability to deal with the fluid.  If by some miracle he is able to manage his fluid intake without dialysis, his kidneys will not be able to manage the waste products and his potassium levels will become so critically high that he will die from cardiac arrest...

So that sucks.

He will continue to be a drain on the system, getting "free health care" because no hospital will turn him away.  This is not near to the cost if he actually received dialysis three times a week, four hours at a time like he probably needs.  But it will still be a cost to the taxpayer. This sporadic treatment given as a result of recurring crisis will take it's toll on his body, and his kidney disease will progress rapidly.

And then he will die. 

So that sucks even more.

As I spoke to Juan today I realized that putting a face to something changes your perspective.  I'm not saying that illegals should all get free health care.  That would just be crazy.  What I will say is that it's a lot easier to say "kick 'em out of the country" when you're talking about a nameless, faceless person.  What will happen to him if he returns to Mexico?  Will he get treatment?  I can't imagine that he will get the level he would here.  I imagine he would be treated from one crisis situation to the next.

But maybe I'm wrong.

All I know is that he is a man.  A human being with a family and friends and hopes and dreams of a better life.  He is a creation of God.  He has a scary diagnosis that I don't think he understands.  I pray for his safety.