Firstly, I want to render an apology to turnberryknkn, because I know it's not his fault that his state is all messed up, but I am so angry with Michigan that I could just spit, and it all has to do with Medicaid.
In essence: Michigan Medicaid does not reimburse out of state providers for costs incurred by Michigan Medicaid recipients. I cannot see MI-Mcaid patients at the clinic except for a one time follow-up - we're not a provider, and we're across the state line. Our front office staff basically forbids it, because Medicaid is such a picky thing.
And now that that preface is out of the way, I want to introduce you to C.
I met C one night on call, when the ER doctor dragged me out of bed and down the stairs to meet a man who'd been woken from his sleep. He was pleasant, talkative, mid-forties, and very frightened. You see, one of the unwritten rules ofowning a body is that it should do what you tell it to and only what you tell it to. It should not, for example, awaken you a little after midnight by doing the Tomahawk Chop all by itself. In layman's terms, something is very wrong when that happens, and most people instinctively know that. Most people instinctively also know that the reason your body is acting on its own is that something is very wrong with your brain.
The brain frightens people. It frightens me. It's a great big thing with the consistency of Jell-O sitting up in your skull thinking all the time. It's hard to separate your brain from yourself, really, and yet it's sort of a separate entity. And everyone seems to know that when something is wrong with your brain, then nothing good can come of it. So C came in frightened, and we had nothing good to tell him.
I've got a sad case for you, the ER doc says to me. Here's a guy, smoker, mid-forties, woke up with his right arm doing karate chops. He's got a big mass in his chest and a couple little ones in his brain. And I know and he knows, in the undertones, that what he's saying is that here is a man who probably has metastatic lung cancer and is going to die.
I called the oncologist, called my staff, spoke quickly and concisely. And I asked C if there was anything I could do. He understood the situation, sighed. "What is there to do?"
Two days passed before I got the call from the radiologist. He'd gone down for a staging CT scan - chest-abdomen-pelvis, what can we find? Radiology called me up: You ought to know, before you biopsy. There's a big cavitary lesion here, looks more like infection. I recommend an MRI looking at that brain for abscess.
That's like going from death sentence to "possibility of parole", O Best Beloved. A brain abscess is a big deal, and it's potentially deadly, and it's hard to treat, but it can be treated. Brain-metastatic lung cancer is one of those diseases where palliation - improving quality of life rather than aiming for a cure - is the order of the day. Brain abscesses are treatable. We got the MRI.
MRI center called me. "Looks like an abscess to me." And so I called Infectious Diseases, and then on his recommendation I called Pulmonology and then I called Neurosurgery. Full-court press workup. Pulmonology did a bronchoscopy with transbronchial biopsies, and then the fun began.
By the next day, the biopsies had been lost - potentially sent to Utah - and the hunt was on for them.
Neurosurgery cruised by the chart every day writing a note of sorts:
"Afebrile. Dil level = (the day's anticonvulsant serum level). *illegible scribble*"
ID cruised by the chart every day and wrote a note that took twenty minutes to decipher:
Hey, can anyone read this? "Says...Wrong HIV test ordered AGAIN...something something biopsies....something something Michigan...something something antibiotics. Oh, and an order: Write TB test results HERE."
Fortunately, he also usually stopped by to swear at me about the complete incompetence of the hospital staff, so I got his update. He was also the one who informed me that what we really needed to do was to send this man to a Michigan hospital where they could follow-up with him somehow.
Heme-Onc cruised by the chart every day and wrote a note that was supremely unhelpful:
"Afebrile. No new seizures. Await biopsy results."
Pulmonology wrote a similar note, usually with an update on the status of the biopsies, and sometimes a speculation of what they would show.
Days passed. We determined that the biopsies were probably in Utah, then that they were definitely in Utah. They were being Fed-Ex'd back to the hospital. And all this time I'm working on discharge planning. And here, O Best Beloved, is where it breaks down.
Of my four consultants, only one had an office in Michigan and could serve Michigan Medicaid patients. The other three were going to be completely unhelpful, because there could be no follow-up. For my part, I went straight to Social Work.
"I have a patient here who's Mi-Caid pending. He's going to need a primary care physician to serve as a coordinator for his medical care." Because, O Best Beloved, primary care doctors are ideal for coordinating care. "Who can I send him to?" And she took a deep breath.
There are, it appears, a vanishingly small number of providers in his part of Michigan who take Medicaid. So few, in fact, that there were potentially no doctors at all for this man's primary care. She had a phone number of someone forty minutes or more away who might be able to find a provider in that region, possibly, if they weren't all full. And in the meantime he's spending all his time sitting in the hospital waiting for something to happen, and he would just as soon wait for us to give him his news at home as here. So I set up arrangements for him to see the one primary care physician I know he can see once : me. And I set up arrangements for him to see the oncologist in Michigan. And we send him home to await biopsy results.
Saturday morning, I get a page from ID. "You've got the nonspecific ST-T wave changes of biopsies here," he says. "We have to start over." And so on a Saturday morning I have to call this man and tell him that not only do we not have an answer, we don't have a clue how we're going to continue from here, but that I'll get in touch with people on Monday and formulate a plan. And he says to me:
I thought I'd been kicked out of your health system. How are you going to do that?
That broke my heart. And I told him that I wasn't giving up on him, no matter what, regardless of whether I was getting paid. I was going to keep trying to organize this until I could find a Michigan physician to take over. He sounded dubious, but he thanked me.
Monday I called the oncologist in Michigan. PET-CT won't be covered by Medicaid, he says. We'll have to do serial CT's and watch to see what happens. And I could have screamed. Here, O Best Beloved, is a nice man with a very severe problem who is being denied diagnostic studies because he's poor. These are studies that could make the difference between life and death - but Medicaid reimburses $40 for a PET-CT with read, so you can't get one. And the neurosurgeons aren't serving Michigan, so the brain biopsy is right out until someone finds this man a neurosurgeon or ID doctor in Michigan. And I don't know anyone in Michigan.
I called the patient, told him he needed to get in to see the oncologist as soon as he could, and talked with him for a bit. "My right leg is a little weak," he says. "But I think I might just be tired." I told him that if it didn't get better, he needed to get to an ER right away. Can't see him in the clinic.
The next day, triage nursing took a call from the patient's mother. "C can't use his right side at all." And I told them to tell her to go to the ER. In Michigan. And I crossed my fingers that maybe someone there would be able to get him the care he deserved.
And I could just cry.