The moral and economic need to ration healthcare.

This folks is what is coming for the rest of the US.

Remember in my last post about wait times in the ER when I said that the emergency room is the arterial hemorrhage of funds in a hospital?  Well, thanks to COBRA (a federal mandate that all patients must receive a medical evaluation and stabilization regardless of their ability to pay) we can’t shut down services (and a good thing or I’d be out of a job) but tough times are a comin’…

A hospital group I don’t work for but am familiar with from working as a paramedic & transporting patients to has a novel way of putting a tourniquet on their bleeding ER:  they have a doctor working in triage.  Thus, patients get a medical evaluation by a licensed professional, and if they don’t meet ’emergency’ status (urgent but not emergent) they must pay their full copay.  Up front. Before being seen.  You know, they don’t have very many drug seekers at their emergency room doors any more.

Now on to the reason for the title of my post.  Above are some of the economic reasons, partially.  Below will be some of the moral reasons.

I am a paramedic in addition to being a nurse.  I have 15 years of experience in emergency medicine, in everything from extreme rural situations to urban, along with critical care flight experience.  So I think that I have the empirical experience to make some value judgements about how we ration healthcare in this country.

Why do we work trauma codes?  This is when someone is so gravely injured at the scene of an accident that they die.  These people sometimes have an electrical rhythm on the ECG monitor but they almost never live, even with the best care and best most dedicated surgeons.  I can think of only one in 15 years that lived, he was 22 and still had some brain damage; what saved him was being 6 blocks from a trauma center and only having bled out from being stabbed in a bad spot, not having serious injuries.


There was a patient, two really, from a motorcycle crash recently.  The first patient died on scene but the crew worked him and sent him by helicopter to the hospital.  He ‘lived’ for another several hours including 4 hours in surgery; the other patient had injuries but will live.  The pt who was worked used in the teens of units of blood, forced the closing of a trauma center due to all resources centered on him, and incurred in the hundreds of thousands of dollars of medical treatment, essentially to give false hope to his family.  Why?  Why do we do this?  Even if he made it through surgery he wasn’t going to make it out of the hospital; his age and extent of injuries made that pretty well impossible.  Why do we expend such huge resources on patients who are not going to live??

The second patient was from a long term care facility.  This patient was essentially a vegetable, who coded when the trach got bent and the patient was deprived of oxygen.  So, the patient was worked, gotten back…for what?  Why did we expend such large amounts of resources on someone who had ZERO quality of life to begin with…and still has ZERO when we are done?  This person will still be on a ventilator, will still never wake up, and will live out their days in a bed in a long term care facility.

Third patient was an infant.  Baby was being held in mom’s lap, because parents are illegals and don’t know about car seat laws.  Dad got in an accident, got Tboned, car got spun around and baby was flung from mom’s arms out the window.  Kid had an open skull fracture with brain matter hanging out, also was dead on scene.  This baby got worked anyway, got transported into the trauma facility, and of course died anyway.  Why?  Why did we expend resources on this baby?  Why did we give false hope to the parents that their baby would live?

I know I sound cold and heartless when I write about ‘expending resources’ as though it’s all about money.  Well, realistically, it IS all about money.  Even if we had universal healthcare, there would still need to be a discussion about rationing healthcare.  Who pays for the people who are vegetables living in nursing homes?  You and I, the working taxpayers do.  Who pays for the 97 year old stroke patient who will never get better, who lands in ICU for a month before he dies?  You and I, the working taxpayers do. I personally would rather invest my tax dollars into preventative healthcare for all the uninsured community members I live among.  I personally would rather invest my tax dollars into dental care for those same community members.  I would much rather invest into comprehensive healthcare — universal healthcare if you will — for ALL the children in my neighborhood.  I have seen too many tragedies resulting from the lack of access to basic health and dental care; one of my neighbors died last year from an abcessed tooth.  By the time she was sick enough that her husband insisted on taking her to the emergency room, she was already dying from the abcess.  It had eaten through the skull bone and gotten to her brain.  She left a husband and three kids without her.  Why?  Because she was working, as was her husband, but couldn’t afford health/dental insurance.

I respect peoples’ religious choices even when I don’t agree with them.  However.  There needs to be a realistic discussion about who is going to pay for this stuff when it is unreasonable medically, ethically, morally, and financially to expend the resources needed to keep them ‘alive’ at the expense of the rest of us and our ability to seek and get affordable healthcare.  Not to mention the emotional costs to everyone involved – family, friends, AND staff caring for them.  I personally think that if families want to keep their loved one alive at all costs then it should be on them to shoulder the cost.  People would make much smarter choices about keeping loved ones ‘alive’ if it was a choice between their house or the long term care facility.  Cold hearted?  Yes.  Realistic?  Also yes.  Have I made that choice myself?  You bet.  My mom died at our house.  I refused to allow them to transport her and work her.  They would have, time down and other factors made it an ‘allowable’ choice but I would not submit her to that indignity.  She was never going to come back.  Her long term health condition made that impossible, not to mention her age.  It was awful.  But it was the right choice.

In future years, the high energy ways of extending life and using resources profligately will simply not be possible any more. Thus, our failing economy, and the realities of peaking oil and a lower energy future make this an urgent discussion topic.  We MUST ration healthcare, this is reality.  The questions are:

how do we divide up the ever shrinking pie? I vote for preventative maintenance.

who is more important? I vote for children and otherwise healthy adults, who will continue to contribute if they get timely healthcare.

how do we shift the paradigm?  I suspect that economic realities will do it for us, but personally I would much rather see proactive discussion on this topic.

Edited to add this blog post I came across; he says basically what I do but has lots of links and stats to back up what we’re both saying.

One response

  1. My Mom has been a nurse for 25 years working in cancer care and has said some of the same things. Would we rather pay 100K on a trauma workup for one person who is going to die anyway or provide preventative dental care for 500 kids? I don’t think it’s cold-hearted, it’s about choices. You can choose to give care to more people that it WILL make a difference to, or to ONE person, that it really won’t. Most people just can’t confront reality in this way.

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