A gift, not a right

Written by Richard Trotter

Before I get into the meat of this rant I'll explain where it comes from. I'm a 31-year-old critical care nurse who works in the Emergency Department of a Level Three facility, in an urban centre in the "Golden Horseshoe". I have been a nurse for 6 months or so. Prior to beginning my career in nursing I worked as a Correctional Officer in a medium and maximum-security provincial jail.

I'm going to rant about responsibility, and specifically responsibility regarding healthcare. In this province, and in fact nation wide, Canadians live with the knowledge that, should the need arise, we will receive excellent health care. There is no need for outside insurance; the homeless and unemployed receive the same access to care as the rich and famous, more or less. We attempt to distribute our resources based on need, and triage our patients accordingly. Admittedly this is not a perfect system, and it is not necessarily the most convenient for the individual who has a problem that is interfering with their lifestyle, but that isn't immediately life threatening, but for the most part it works.

So what has me "pissed off"? Well I think that there is a difference between healthcare being available for those who need it and the general assumption that "I have a right to healthcare regardless of the choices that I have made". I see healthcare as a shared resource; a gift from one member of society to another, not something that is a "right" and to be expected regardless of circumstance.

I believe that, if I make some lousy choices, don't follow the advice of trained healthcare professionals for an extended period of time, and constantly put demands on a limited resource, then I should have less access to this resource in the future. I have seen 70 year olds, with Acute Coronary Syndrome (a range of problems spanning the spectrum of High Blood Pressure to Acute Myocardial Infarction, Cardiac Arrest and death) and with COPD (Chronic Obstructive Pulmonary Disease - long term Asthma, emphysema, etc) who continue to smoke, eat poorly, get little or no exercise and who return to the ER on a regular basis for "symptom relief". There are diabetics who pay no attention to their diet and exercise, fail to take prescribed medications and who are seen repeatedly for hyperglycemia and diabetic ketoacidosis. These same people are at increased risk of heart disease and peripheral vascular disease (which, among other things contributes to poor wound healing and the potential need to amputate infected body parts). There are more young people out there abusing the "recreational phamasueticals" and creating all sorts of health problems for themselves than I had imagined (remember I worked in a jail before a hospital and I'm still amazed by the number we see in the hospital each week).

So what is the answer? On the one hand we all pay for healthcare and therefore all feel that we are entitled to it. On the other hand we all know (or should know) that healthcare dollars are limited, and perhaps more importantly, the professionals and equipment necessary to care for the very ill are in short supply.

I don't know. I want to care for the ill and the injured. If I didn't I'd have quit the first time some old person shit the bed because they couldn't get up, because they were too weak and couldn't breath well enough to get to a bathroom. Or the first time a junky puked down my shirt. Or the time I had to wrestle with a drunk who'd punched a window, cutting his brachial artery in the process and had nearly bled to death, but was insistent that he was fine despite the 3 litres of blood he'd lost. I think what I want is for the ill and injured to want to care for themselves. I'm tired (already) of working my ass off and watching my colleagues work their asses off to help people who just don't seem to care.

Here is an example (true story ? no names for confidentiality)

Yesterday a young girl arrived in the ER. She's been living on the street for a week (since she got out of jail). Her face is swollen and her eyes are black. She is dirty and obviously hasn't washed in a while. She is staggering, agitated, and unable to carry on a conversation. We suspect a head injury, potentially something serious. We don't know whether the swelling in her face is because of broken bones. We don't know if she is bleeding into her brain. After being in the ER for a couple of hours her level of consciousness drops, she stops responding when we talk to her. It appears that her condition is getting worse. She needs a CT Scan, but she needs to stay still while it is being done. She fights us when we try to move her, another indication of a head injury. We have also learned that she has been using Crack Cocaine, and probably been prostituting herself to pay for it. The doctor decides that she must have the CT sooner rather than later. She gets moved into our Trauma Resuscitation room so that we can sedate her. Unfortunately if we sedate her she'll stop breathing, so we'll also have to intubate her (put a tube in her mouth and down her trachea to keep her airway open. It takes 6 of us to hold her down so that we can get an IV in and get the sedation onboard. An Anesthetist intubates her. A Respiratory Technician connects her to a mechanical ventilator and oxygen. We put a catheter in to drain urine from her bladder, and take her to CT. Two nurses, the respiratory technician, and a Trauma surgeon accompany her. In CT two radiology technicians and the radiologist assist us. She starts to wake up; we give her more sedation. She starts to wake up again; we give her more sedation again. She wakes up a third time and, with her head still in the CT Scanner, and me pushing more sedation into her IV she struggles, grabs the tube that is keeping her airway open and pulls it out. She begins to vomit, and promptly stops breathing. We turn her, suction the vomit out of her airway and rapidly begin the process of manual ventilation. We get her out of the scanner; we can't finish the scans because we must maintain her airway. We rush back to the Trauma Suite and get ready to re-intubate. Once she is intubated again we get some x-rays done, do an electrocardiogram and transfer her to the Intensive Care Unit. We got the first of three series of CT Scans done. The rest will have to wait. The first set looked good, no obvious bleeding in the brain, no broken bones.

So in summary:

1 ER physician ($140-$180/hr) x 2 hrssay $160 x 2 = $320
1 Trauma Surgeon ($200/hr) x 2 hrs$400
1 Radiologist ($200/hr) x 1 hr $200
1 Anesthetist ($200/hr) x 1 hr$200
6 ER Nurses ($22-35/hr each) x 1 hrsay $30 x 1 $180
2 ER Nurses x 4 hrs$120
1 Respirator Tech ($25/hr) x 5 hrs$125
Drugs and equipment (ER)say $1000
Basic cost of admission(covering misc costs ie. Clerks, restocking, etc.)$250
CT Scansay $2000
ICU Bed (approximately $2500)$2500

For the most part the numbers above are an educated guess ? I didn't check with the hospital finance department to verify them. But the above scenario cost, about $7500 assuming that there was minimal work beyond "routine" ICU work once she was transferred. This excludes the costs associated with X-ray, X-ray technologists, the Electrocardiogram (which I did myself, so we only have to worry about the cost of the machine) and a few incidentals because I forgot them when I was totaling up the costs. And why ? because she didn't care enough about herself not to use Crack, stay off the streets and not prostitute herself.

The sick thing is we see this every shift of every day.

Here is a proposal:

Health care is free for all children and minors to the age of 18 (every one needs the opportunity to learn). Everyone is allowed 4 ER visits each year to cover truly emergent situations and accidents. If you don't use your visits in a year too bad, there is no carry over. Any repeat visits for the same problem that has already been treated in the past, when there is any evidence of not following prior medical instructions, shall be billed, at full cost to, the patient or their estate. Visits of a routine nature, not requiring ER facilities shall be billed to the patient or their estate. Any injury or illness that can be shown to be self-inflicted (intentionally or unintentionally, including injury or illness as a result of illegal drugs, use of alcohol or tobacco) shall be billed to the patient or estate at full cost. In the cases that are covered by the province through OHIP, a statement shall be sent to the patient so that they are aware of the "gift" that they have received.

I know that this is not a perfect plan but it has to beat all of us paying for the retards of this world who don't or won't accept responsibility for their own health care.