Up close and personal
with the U.S. Health Care Trauma System
October 16, 5:17 P.M. I received the call, “Your son has been hit by a
car. “At this point everything slowed down inside my head and all noise from
the outside world was muffled. First, I breathe and then ask, is he conscious?
Thankfully, he was alert according to the paramedic on the scene. He was being
transferred to the local hospital emergency room for further treatment. By this
time it is too late to make it down to the 5:30 ferry, so I was relegated to
the 6:45, which means I wasn’t on the beach to see my son until 7:45P.M. I gave
the paramedic my information and called the hospital giving them my E.T.A.
Traumatic Brain Injury
8:00 P.M. I arrive at the local hospital, a 262 bed facility with a
Level III Trauma Center, and immediately found my teenager in the E.R. The
treating physician informed me that he had multiple fractures, on his head
and leg, the most worrisome of which was the skull fracture. (My son had just
bought his new skateboard and did not have his helmet at the time of the
accident.) The first thing Nathan says when he sees me is “I’m sorry Mom,” and
then he starts asking for pain medication, yet he was calm, and composed. The
doctor informs me the head trauma has caused a brain bleed, and Nathan needs to
be transferred to a pediatric trauma center. At this point, I requested Seattle
Children’s Hospital for the transfer, but it turned out that Harborview Medical
Center had the pediatric –neuro-rotation for that night. So off we went in the ambulance to the Level I
Trauma Center, which is funded by the State through the University of Washington.
If you haven’t experienced the controlled chaos of an urban trauma
center, it is reminiscent of a mental health ward, serves as a repository for
the homeless in varying degrees of inebriated battle-weary skirmishes, and of
course, is the collecting point for trauma victims. Some patients were on
gurneys in the hallway while more urgent cases were treated in the E.R. suites,
which were divided only by a curtain which runs two feet above the ground, and
circles the bed like a shower curtain. Consequently you can hear everything in
the ward, which can be somewhat disturbing.
Patient Safety Observations
Nathan was admitted to Harborview at 11:10P.M. October 16th. Throughout
the night teams of specialists came in to examine him and he was not allowed to
sleep until he could be fully evaluated, after the C.T. scan(s). Teams included
pediatric neurological surgeons, general care pediatricians, orthopedic
surgeons, and ortho/maxillofacial
surgeons. Procedures which he
endured included putting a cast on his leg and a second cast on his arm, which
was later removed after it was discovered there was no arm fracture, and lots
of tests. Unfortunately whoever installed the I.V. line did not removed the
tourniquet after finding a vein and it was allowed to linger on his arm until
the next day. This included some nurse actually attempting to put a blood
pressure cuff over the tourniquet, which was high up on his arm and slipped
under the cap sleeved gown. The tension of the tourniquet left a circular
barbed-wire-tattoo on his arm. If he had circulatory problems this safety lapse
may have caused severe problems. During his hospital stay, the phlebotomist
came in to draw blood and asked if he was the patient in Bed A or Bed B, and I
said I don’t know what bed this is, but he is my son and his name is Nathan.
Again, isn’t it a better verification to use a patient’s name rather than the bed
insignia?
Shortage of Beds for Patients
October 17, 5:30A.M. Nathan was transferred to the Intensive Care Unit
where he spent two days for observation of his brain bleed, which had doubled
in size but was stabilized. Yes, we spent the night in the E.R., with him on
the gurney and me in a straight-backed chair, because we were waiting for a bed
to become available anywhere in the hospital. This is not an unusual phenomenon
for urban trauma centers, as they received referrals from all regional
hospitals, for Traumatic Brain Injury (TBI) cases, burns, and other traumas.
Children of course get top priority, so a bed was found. Literally, this trauma
center does not have enough beds for its patients. The Intensive Care Unit (I.C.U.) floor
featured a shared ward with the burn victims and as it turns out, one mental
health patient in the midst of an episode. Though the room was private and it actually
had views of the harbor, the hallway between all of the other “rooms” in the
ward was an open design, separated from the patient’s area only by a curtain.
This meant that sound carried throughout the ward. Thankfully Nathan was loaded
up on some pain medication and I crashed out on one of those folding
bed/chairs.
Who Pays the Bill?
At both the local hospital and the regional trauma center, I was
queried on where I worked, if I had full-time or part-time employment, and
other insurance payment questions. Incidentally, evidence of employment in the
United States does not mean that medical insurance is available to the employee
or her family, as only about half of all businesses offer any type of group
medical insurance. This payment interrogation is part of the
follow-the-money-trail of all health care providers in the United States. Even
though my son had insurance and I presented his insurance card, there is still
the secondary payer inquiry, to allocate fault or payment somewhere else. Speaking
of fault, the ambulance company billed me immediately and assumed that because
my son was hit by a car that it was an auto insurance claim and asked for that
information. Of course these questions
are routine and did not drive my son’s health care, but they serve as a
constant reminder that our health care system is always about the money trail.
Because the United States lacks a national health care program, we must concern
ourselves with the ugly word, subrogation, which is an insurance industry term
for assigning blame in order to obtain payment or reimbursement. In fact, at
12:04P.M., on October 18th, I received a call from the man who drove
the car which hit my child, asking for money to fix his truck. Aside from the
ghoulishness and timing of the request, it too reflects on a predominant driver
in the U.S. health care system, which is getting paid.
Follow-up Care
Fortunately our follow-up care at Children’s Hospital was a marvel,
with concierge-type service from department to department, making fast work of
the registration and verifying patient identity quickly, and with humor.
Another marvel was the complete lack of any measurable wait time at Children’s
Hospital as compared to the follow-up care we also completed at the trauma center.
While at the latter a hospital volunteer retrieved an unconscious man who was
unable to speak from the “drive-up” and wheeled him to the X-ray and imaging
department. Though I have difficulty imagining what family member would leave
someone this vulnerable without an advocate, I was reassured when I saw him
alert later in the day when he was waiting for his ride home. In conclusion, a
patient advocate is always a good idea during a traumatic event as the family
member and the patient may be too upset to make good decisions.
Implications for the Hospital
Safety Net
With the implementation of the Affordable Care Act in 2014, more
employees will have access to affordable health insurance through federal subsidies
and insurance exchanges, regardless of what their employers are doing, so the
full-time or part-time work question will become less important. But what
remains is an acute shortage of hospital beds, especially in urban trauma
centers and this will require an infusion of cash to overcome. Though
Disproportionate Share or DSH hospitals like Harborview do receive additional
funding from the federal government, it is not enough to finance a building
expansion. The resourcing of health care falls to the local hospital district
which will have to raise the money through a bond issue or some other means. We
cannot afford to staff every hospital with the neurological and other specialty
personnel required for Level I Trauma Centers, so surely we must do everything we
can to preserve the ones we have. Since 2013 will focus on the budget crisis I
hope lawmakers will consider the hospital safety net when they make their cuts.
And this is the healthpolicymaven signing off in real time.
This article was written by Roberta E. Winter, MHA, MPA, a health care journalist,
consultant, and mother.
