More Medical Deportations

As previously discussed on this blog, medical deportations are a tragic reality. The cases are sad enough when the deportees are illegal immigrants, but what happens if they are in fact legally in the U.S.? Another shameful medical deportation:

Soon after Antonio Torres, a husky 19-year-old farmworker, suffered catastrophic injuries in a car accident last June, a Phoenix hospital began making plans for his repatriation to Mexico.

Mr. Torres was comatose and connected to a ventilator. He was also a legal immigrant whose family lives and works in the purple alfalfa fields of this southwestern town. But he was uninsured. So the hospital disregarded the strenuous objections of his grief-stricken parents and sent Mr. Torres on a four-hour journey over the California border into Mexicali.

For days, Mr. Torres languished in a busy emergency room there, but his parents, Jesús and Gloria Torres, were not about to give up on him. Although many uninsured immigrants have been repatriated by American hospitals, few have seen their journey take the U-turn that the Torreses engineered for their son. They found a hospital in California willing to treat him, loaded him into a donated ambulance and drove him back into the United States as a potentially deadly infection raged through his system.

By summer’s end, despite the grimmest of prognoses from the hospital in Phoenix, Mr. Torres had not only survived but thrived. Newly discharged from rehabilitation in California, he was haltingly walking, talking and, hoisting his cane to his shoulder like a rifle, performing a silent, comic, effortful imitation of a marching soldier.

“In Arizona, apparently, they see us as beasts of burden that can be dumped back over the border when we have outlived our usefulness,” the elder Mr. Torres, who is 47, said in Spanish. “But we outwitted them. We were not going to let our son die. And look at him now!”

Antonio Torres’s experience sharply illustrates the haphazard way in which the American health care system handles cases involving uninsured immigrants who are gravely injured or seriously ill. Whether these patients receive sustained care in this country or are privately deported by a hospital depends on what emergency room they initially visit.

There is only limited federal financing for these fragile patients, and no governmental oversight of what happens to them. Instead, it is left to individual hospitals, many of whom see themselves as stranded at the crossroads of a failed immigration policy and a failed health care system, to cut through a thicket of financial, legal and ethical concerns.

While one can empathize to some degree with hospitals that do not have the funds to adequately care for patients with questionable legal status, knee-jerk deportations are certainly not the solution. While deportations may be necessary in some cases, they should clearly be a last resort and even then, only instituted by the proper legal authorities, not in an unregulated manner by hospitals. The problem is systemic, but it is one we should all be ashamed of.. Patients, legal or not, deserve better.

Federalism and Pharmaceuticals

There's an interesting Supreme Court case coming up. The case deals with whether drug-makers are liable for side-effects of medications that occur, even after the drug label/warning is approved by the FDA. There's an interesting discussion about patients vs. big pharma on the Healthbeat Blog (via KevinMD):

First, the details of the case: In the spring of 2000, Diana Levine of Vermont received treatment for migraines which consisted of the painkiller Demerol and Phenergan, an antihistamine manufactured by Wyeth Pharmaceuticals. Phenergan is typically injected directly into the muscle or dripped into the vein through steady doses (a procedure called an “IV drip”). When administering the drug, clinicians must be careful not to expose it to blood in the arteries; doing so causes “swift and irreversible gangrene,” to use an evocative phrase from a September New York Times article on Levine’s case.

Unfortunately, the physician assistant who attended to Levine administered Phenergan neither through muscular injection nor IV drip, but through a process called “IV push”—a direct intravenous shot in the arm. The assistant missed and hit an artery. Over the next few weeks, Levine, who was an avid guitarist, saw her right hand and forearm turn purple and then black—until both were finally amputated.

The court battle is over whether or not Wyeth Pharmaceuticals sufficiently warned against the dangers of IV push on its packaging for Phenergan—packaging that had been approved by the FDA. The drug’s labeling did warn that it was preferable to give Phenergan through IV drip, and warned that “inadvertent intra-arterial injection”—accidentally injecting the drug into an artery—could cause “gangrene requiring amputation.” But nowhere on the Phenergan label was there an express warning that the method of IV push is extremely risky for this very reason.

I'm Sorry?

The NYTimes' 'Doctors Start to Say ‘I’m Sorry’ Long Before ‘See You in Court’' is reassuring to me in a funny way. I have always thought the malpractice system in the U.S. made no sense, but it's nice to see some progress being made on this front. I don't think all lawsuits are frivolous: patients injured due to negligence or incompetence should receive care and compensation, but it takes real skill to separate unavoidable mistakes from true negligence. Having an open and frank discussion is the first step in that direction:

For decades, malpractice lawyers and insurers have counseled doctors and hospitals to “deny and defend.” Many still warn clients that any admission of fault, or even expression of regret, is likely to invite litigation and imperil careers.

But with providers choking on malpractice costs and consumers demanding action against medical errors, a handful of prominent academic medical centers, like Johns Hopkins and Stanford, are trying a disarming approach.

By promptly disclosing medical errors and offering earnest apologies and fair compensation, they hope to restore integrity to dealings with patients, make it easier to learn from mistakes and dilute anger that often fuels lawsuits.

Malpractice lawyers say that what often transforms a reasonable patient into an indignant plaintiff is less an error than its concealment, and the victim’s concern that it will happen again.

Despite some projections that disclosure would prompt a flood of lawsuits, hospitals are reporting decreases in their caseloads and savings in legal costs. Malpractice premiums have declined in some instances, though market forces may be partly responsible.

Hopefully I'll never be placed in this situation, but I think if I am, this seems to be the only conscientious way to approach my error. I guess I should just pray that the patient understands that medicine is a human endeavor and thus, subject to the same human failings of any other field.