Indigent Medical Care

I find it truly amazing just how full of shit some professionals are and how they treat their colleagues.
I live and work in Riverside County in Southern California. The _county hospital_ is Riverside County Regional Medical Center in Moreno Valley. As the _county hospital_ they receive funding from the state to care for the indigent population of the county. (For those that don’t know, that means patients without insurance.)
Because of the EMTALA and COBRA laws it is illegal and punishable to _dump_ or transfer a patient to another facility if they are unstable, unless you don’t have the facilities at your institution to stabilize them. Stabilization can and sometimes does include having to operate on the patient. That’s where I usually come in. It’s not that I mind getting up in the middle of the night to take care of someone that not only will likely cost me more in money and risk (of being sued) than I would ever hope to collect that bothers me the most. I expect a certain amount of that. After all, it’s part of what I do for a living — or is it. That’s the subject of another story.
On Wednesday, April 11, 2002 I was called to the ER to evaluate a patient with gas gangrene of the leg. Nasty infection, indigent patient who really needs source control of his infection that night. In layman’s terms he needed his lower leg amputated. No problem. I’ve been trained to do that. I’ve even taken care of these patients during my training. Of course, in my current practice I don’t take care of these types of problems.
OK, I take the patient to the OR, amputate the correct leg, (it really was obvious) and stabilize the patient for transfer to the _county hospital_ for further care. The patient will need further care. Probably 2 more operations, if he’s lucky and doesn’t loose his leg at the hip joint. Did I mention that I actually grossed out my pathologist?
Well 2 days later the patient is out of the ICU and doing reasonably well. I call the chief surgical resident (Dr. Joe Boskind) to see about transferring the patient. He refused to speak with me. In all honesty I probably deserved it as the night this particular patient came in I was trying to transfer another indigent patient, who was stable and didn’t need an operation, to him. At that time I got a dissertation from him about the cost of accepting indigent patients to his hospital and that the surgical problem wasn’t difficult and I should be able to take care of it. I asked him if his salary was dependent upon patient reimbursment – it wasn’t. I asked him if the surgery department was responsible for the fiscal well being of the hospital – it wasn’t. I asked him why, as a surgical resident, he even cared whether or not the patient had insurance – he had no answer. I briefly explained to him that it appeared that a lot had changed since I was a surgical resident. Yes I raised my voice – I was pissed off. I was good though, I didn’t insult him personally and to his credit he didn’t hang up on me. At the end of the conversation I asked to speak with his attending.
My conversation with the attending (Dr. Clifton Reeves) was very pleasant. He was courteous and direct, as was I. I told him that I had always had problems trying to transfer patients to his hospital and had always met with resistance. I asked him what it would take to have a patient transferred. I stated that as long as the patient didn’t require surgery that night that they would accept the patient in transfer. He also stated that they would accept the patient in transfer post-operatively too. I told him to expect a call in a couple of days.
Now a couple of days later I call and happen to speak to that same chief surgical resident. Like I said before, he politely declined to speak with me. I asked to speak to his attending. I tried to speak to the same attending surgeon that I had spoken to on the previous night but he was gone. I was connected to an attending surgeon (Dr. Carlos Balerezo) whose manner could be at best described as gruff and at worst be described as hostile and rude. He had no interest in listening to the patients information or in accepting him in transfer. When I told him that this was not the type of care that is usual and customary in my practice he told me to find someone at my hospital to take care of the patient. I asked who the Chief of Surgery was and he replied that he was. I said thank you very much and hung up.
Am I missing something obvious. This is a teaching hospital that regularly takes care of these types of problems and gets money from the state for these types of patients. And they blew me off.
I was pissed. I called our State Senator Jim Batten’s office and explained my problem. They were very helpful. I told them that since this is the typical problem that we encounter from the Department of Surgery at the _county hospital_ that perhaps the state funding they get for this type of care could go into a pool to pay for the hospitals and doctors who really take care of these patients.
Too soon for a response. But I also plan on calling the Chief of Staff (Dr. Alex Vincent) of the hospital and the Medical Director of the hospital (Dr. Benson Harer) to complain. Am I being unreasonable, let me know.
**Update**
My patient has now returned to his family in Montana. He underwent 2 operations. His initial below knee amputation and then a revision above knee amputation a few days later. He recovered very well and thanks to a Wound-Vac healed his open stump very nicely. All in all he spent about 4 months as a guest of our hospital.

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